Incident Learning Systems for Radiation Oncology: Development and Value at the Local, National and International Level

Abstract

Aims: To discuss the background for incident reporting and learning systems, as well as the infrastructure and operational aspects to run them.

Materials and methods: Information from peer-reviewed literature, online resources and the authors' experience synthesised into a concise understanding of the topic.

Results: Incident learning systems can be local, national or international, each having the same basic goals but facilitating different audiences and environments. A key component of any reporting and learning system is timely and effective analysis of near-misses and incidents as well as feedback to the users of the system. It is important for staff to know that reports are acknowledged, analysed and acted upon. There is a need to comply with current European legislation and other national systems, which can be addressed together with the steps required for comprehensive management of an incident.

Conclusion: Reporting and learning from incidents and near-misses is a key component of quality and safety in radiotherapy. A major benefit of the national or international systems is the potential for a larger database of incidents, supporting wider analysis and comparison, and sharing of knowledge across a larger community.

Keywords: Causal analysis; incident learning system; reporting.