Patient safety is improved with an incident learning system-Clinical evidence in brachytherapy

Abstract

Background and purpose: Health leaders have advocated for incident learning systems (ILSs) to prevent errors, but there is limited evidence demonstrating that ILSs improve cancer patient safety. Herein, we report a long-term retrospective review of ILS reports for the brachytherapy practice at a large academic institution.

Material and methods: Over a nine-year period, the brachytherapy practice was encouraged to report all standard operating procedure deviations, including low risk deviations. A multidisciplinary committee assigned root causes and risk scores to all incidents. Evidence based practice changes were made using ILS data, and relevant incidents were communicated to all staff in order to reduce recurrence rates.

Results: 5258 brachytherapy procedures were performed and 2238 incidents were reported from 2007 to 2015. A ramp-up period was observed in ILS participation between 2007 (0.12 submissions/procedures) and 2011 (1.55 submissions/procedures). Participation remained stable between 2011 and 2015, and we achieved a 60% (p<0.001) decrease in the risk of dose error or violation of radiation safety policy and a 70% (p<0.001) decrease in frequency of high composite-risk scores. Significant decreases were also observed in incidents with root causes of poor communication (60% decrease, p<0.001) and poor quality of written procedures (59% decrease, p<0.001).

Conclusions: Implementation of an ILS in brachytherapy significantly reduced risk during cancer patient care. Safety improvements have been sustained over several years.

Keywords: Brachytherapy; Incident learning system; Medical error; Radiation; Safety.