On the benefits and challenges implementing an incident learning system in an academic radiation oncology department
TimeWednesday, April 144:10pm - 4:30pm EDT
LocationPatient Safety Research and Initiatives
DescriptionIncident learning systems (ILS) have been shown to reduce the risk of potential patient harm by identifying risks allowing for the implementation of interventions [1, 2]. Led by this evidence, our institution implemented an internal ILS for tracking deviations or events. Beginning in 2013, our institution has had its share of successes and faced different challenges while attempting to implement an ILS at a large academic medical center.
The ILS is organized and maintained by our department’s Patient Safety Subcommittee (PSSC) whose responsibility is to review, categorize, and analyze the reported deviations. This multidisciplinary team is comprised of physicians, nurses, medical physicists, dosimetrists, radiation therapists, and other administrative support staff. Each month the PSSC meets to review the previous month’s submitted deviations. These deviations fall into the three categories identified as occurrences, near misses, and process variations. We define an occurrence as an event that actually happened to the patient, regardless of whether or not it resulted in an adverse patient outcome. Near misses are defined as an event that did not reach the patient but could cause harm if it were to reach a patient in the future. Finally, process variations are any event not categorized as an occurrence or near miss.
We will highlight the successes and on-going challenges associated with implementing an ILS in a department that has seen significant growth. In the previous eight years, our department has opened a new hospital, changed electronic medical record systems, changed treatment machine vendors, and has seen the patient volume grow from approximately 80 patients per day to over 200 patients being treated each day. Through these changes, having a robust mechanism to identify and capture, in an organized manner, the deviations that could ultimately affect patient care allowed us implement multiple new interventions, which have provided an extra layer of safety for all patients being treated in our department.
1. Deufel, Christopher L., et al. "Patient safety is improved with an incident learning system—Clinical evidence in brachytherapy." Radiotherapy and Oncology 125.1 (2017): 94-100.
2. Kim, Aileen, et al. "Are we making an impact with incident learning systems? Analysis of quality improvement interventions using total body irradiation as a model system." Practical radiation oncology 7.6 (2017): 418-424.