Patterns of Incident Reporting Across Clinical Sites in a Regionally Expanding Academic Radiation Oncology Department

Byung Han Rhieu, Stephanie A. Terezakis, Stephen Greco, Curtiland Deville, Annette N. Souranis, Amanda Choflet, Theodore L. DeWeese, Akila N. Viswanathan, Wolfram Laub, Todd R. McNutt, Jean L. Wright

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Purpose: We evaluated patterns of event reporting across five clinical locations within an academic radiation oncology department, with the goal of better understanding variability across sites. Methods and Materials: We analyzed 1,351 events reported to a departmental incident learning system over 1 calendar year across the five locations with respect to volume of events, event type, process map location of origin and detection, and event reporter. Results: We found marked variability in reporting patterns, including reporting rate, event type, event severity, event location of origin and detection within the departmental process map, and discipline of event reporters. These differences relate both to variability in process and workflow (reflected by frequency of specific workflow events at each site) and in reporting culture (reflected by volume or rate of event reporting, and discipline of event reporter). Conclusions: These data highlight the variability in reporting culture even within a single department, and therefore the need to tailor and individualize safety and quality programs to the unique clinical site, with the long-term goal of achieving a common culture of safety while supporting unique processes at individual locations. This work also raises concern about extrapolating single-institution incident learning system results without understanding the unique workflow and culture of clinical sites.

Original languageEnglish (US)
Pages (from-to)915-921
Number of pages7
JournalJournal of the American College of Radiology
Issue number7
StatePublished - Jul 2019

Bibliographical note

Publisher Copyright:
© 2019


  • Radiation oncology incident learning system
  • RO-ILS
  • safety research

PubMed: MeSH publication types

  • Journal Article
  • Multicenter Study


Dive into the research topics of 'Patterns of Incident Reporting Across Clinical Sites in a Regionally Expanding Academic Radiation Oncology Department'. Together they form a unique fingerprint.

Cite this