Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Nov;23(11):e13742.
doi: 10.1002/acm2.13742. Epub 2022 Aug 6.

The impact of COVID-19 workflow changes on radiation oncology incident reporting

Matthew E Volpini  1 , Katie Lekx-Toniolo  1 , Robert Mahon  1 , Lesley Buckley  1
Affiliations

The impact of COVID-19 workflow changes on radiation oncology incident reporting

Matthew E Volpini et al. J Appl Clin Med Phys. 2022 Nov.

Abstract

Background: The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS)-a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID-19 pandemic.

Purpose: In this study, we analyzed the number and type of ILS submissions pre- and postpandemic precautions to assess the impact of COVID-19-related workflow changes.

Methods: ILS data was collected over six one-year time periods between March 2016 and March 2021. For all time periods, the number of ILS submissions were counted. Each ILS submission was analyzed for the specific treatment domain from which it arose and its root cause, explaining the impetus for the error or near miss.

Results: Since the onset of COVID-19-related workflow changes, the total number of ILS submissions have reduced by approximately 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to prepandemic data. There was also an increase in the proportion of "treatment planning" ILS submissions and a 50% reduction in the proportion of "decision to treat" ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to "poor, incomplete, or unclear documentation" during the pandemic year.

Conclusions: COVID-19 workflow changes were associated with fewer ILS submissions, but a relative increase in submissions stemming from poor documentation and communication. It is imperative to analyze ILS submission data, particularly in a changing work environment, as it highlights the potential and realized mistakes that impact patient and staff safety.

Keywords: COVID-19; incident learning system; quality assurance.

PubMed Disclaimer

Conflict of interest statement

No conflict of interest.

Figures

FIGURE 1
FIGURE 1
Total number of ILS submissions, and normalized number of ILS submissions per plan of care. During the pandemic years (2020–2021, 2021–2022), there were fewer total ILS submissions, and fewer ILS submissions per plan of care. Note “2018–2019” denotes 13 March 2018 to 12 March 2019, “2019–2020” denotes 13 March 2019 to 12 March 2020, and so forth
FIGURE 2
FIGURE 2
Normalized origin domain representation by year. During the pandemic years (2020–2021, 2021–2022), there was a relative decrease in the number of decision to treat ILS submissions, and relative increase in the number of treatment planning ILS submissions. Note “2018–2019” denotes 13 March 2018 to 12 March 2019, “2019–2020” denotes 13 March 2019 to 12 March 2020, and so forth
FIGURE 3
FIGURE 3
Normalized representation of the treatment planning domain categories. Note “2018–2019” denotes 13 March 2018 to 12 March 2019, “2019–2020” denotes 13 March 2019 to 12 March 2020, and so forth
See this image and copyright information in PMC

References

    1. Clark BG, Brown RJ, Ploquin JL, Kind AL, Grimard L. The management of radiation treatment error through incident learning. Radiother Oncol. 2010;95(3):344‐349. - PubMed
    1. Ford EC, Evans SB. Incident learning in radiation oncology: a review. Med Phys. 2018;45(5):e100‐e119. - PubMed
    1. Pawlicki T, Coffey M, Milosevic M. Incident learning systems for radiation oncology: development and value at the local, national and international level. Clin Oncol (R Coll Radiol). 2017;29(9):562‐567. - PubMed
    1. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Med Phys. 2011;38(1):78‐82. - PubMed
    1. Deufel CL, Mclemore LB, De Los Santos LEF, Classic KL, Park SS, Furutani KM. Patient safety is improved with an incident learning system—clinical evidence in brachytherapy. Radiother Oncol. 2017;125(1):94‐100. - PubMed