An evaluation of departmental radiation oncology incident reports: Anticipating a national reporting system

Stephanie A. Terezakis, Kendra M. Harris, Eric Ford, Jeff Michalski, Theodore DeWeese, Lakshmi Santanam, Sasa Mutic, Hiram Gay

Research output: Contribution to journalArticlepeer-review

31 Scopus citations

Abstract

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.

Original languageEnglish (US)
Pages (from-to)919-923
Number of pages5
JournalInternational Journal of Radiation Oncology Biology Physics
Volume85
Issue number4
DOIs
StatePublished - Mar 15 2013
Externally publishedYes

Bibliographical note

Copyright:
Copyright 2013 Elsevier B.V., All rights reserved.

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