RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience

被引:71
作者
Hoopes, David J. [1 ]
Dicker, Adam P. [2 ]
Eads, Nadine L. [3 ]
Ezzell, Gary A. [4 ]
Fraass, Benedick A. [5 ]
Kwiatkowski, Theresa M. [6 ]
Lash, Kathy [7 ]
Patton, Gregory A. [8 ]
Piotrowski, Tom [9 ]
Tomlinson, Cindy [3 ]
Ford, Eric C. [10 ]
机构
[1] UC San Diego Moores Comprehens Canc Ctr, Dept Radiat Med & Appl Sci, 16918 Dove Canyon Rd,Suite 103, San Diego, CA 92127 USA
[2] Thomas Jefferson Univ, Dept Radiat Oncol, Sidney Kimmel Med Coll, Philadelphia, PA 19107 USA
[3] Amer Soc Radiat Oncol, Fairfax, VA USA
[4] Mayo Clin, Dept Radiat Oncol, Scottsdale, AZ USA
[5] Cedars Sinai Med Ctr, Dept Radiat Oncol, Los Angeles, CA 90048 USA
[6] Amer Assoc Med Dosimetrists, Herndon, VA USA
[7] Univ Michigan, Dept Radiat Oncol, Ann Arbor, MI 48109 USA
[8] Compass Oncol, Portland, OR USA
[9] Clarity Grp Inc, Chicago, IL USA
[10] Univ Washington, Dept Radiat Oncol, Seattle, WA 98195 USA
关键词
D O I
10.1016/j.prro.2015.06.009
中图分类号
R73 [肿瘤学];
学科分类号
100214 ;
摘要
Purpose: Incident learning is a critical tool to improve patient safety. The Patient Safety and Quality Improvement Act of 2005 established essential legal protections to allow for the collection and analysis of medical incidents nationwide. Methods and materials: Working with a federally listed patient safety organization (PSO), the American Society for Radiation Oncology and the American Association of Physicists in Medicine established RO-ILS: Radiation Oncology Incident Learning System (RO-ILS). This paper provides an overview of the RO-ILS background, development, structure, and workflow, as well as examples of preliminary data and lessons learned. RO-ILS is actively collecting, analyzing, and reporting patient safety events. Results: As of February 24, 2015, 46 institutions have signed contracts with Clarity PSO, with 33 contracts pending. Of these, 27 sites have entered 739 patient safety events into local database space, with 358 events (48%) pushed to the national database. Conclusions: To establish an optimal safety culture, radiation oncology departments should establish formal systems for incident learning that include participation in a nationwide incident learning program such as RO-ILS. (C) 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
引用
收藏
页码:312 / 318
页数:7
相关论文
共 18 条
[1]  
Agency for Healthcare Research and Quality, PAT SAF ORG PSO PROG
[2]  
[Anonymous], 2000, ERR IS HUMAN BUILDIN
[3]   THE USE OF CATEGORIZED TIME-TREND REPORTING OF RADIATION ONCOLOGY INCIDENTS A PROACTIVE ANALYTICAL APPROACH TO IMPROVING QUALITY AND SAFETY OVER TIME [J].
Arnold, Anthony ;
Delaney, Geoff P. ;
Cassapi, Lynette ;
Barton, Michael .
INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS, 2010, 78 (05) :1548-1554
[4]  
Bernard-Bruls X, 2010, IAEA NEA INT REPORTI, P1453
[5]   Trend analysis of radiation therapy incidents over seven years [J].
Bissonnette, Jean-Pierre ;
Medlam, Gaylene .
RADIOTHERAPY AND ONCOLOGY, 2010, 96 (01) :139-144
[6]   Patient safety improvements in radiation treatment through 5 years of incident learning [J].
Clark, Brenda G. ;
Brown, Robert J. ;
Ploquin, Jodi ;
Dunscombe, Peter .
PRACTICAL RADIATION ONCOLOGY, 2013, 3 (03) :157-163
[7]  
Dekker S., 2014, ASHGATE PUBLISHING L, DOI DOI 10.1201/9781317031833
[8]  
Fiorino F., 2005, AVIAT WEEK SPACE TEC, V163, P72
[9]   Consensus recommendations for incident learning database structures in radiation oncology [J].
Ford, E. C. ;
de Los Santos, L. Fong ;
Pawlicki, T. ;
Sutlief, S. ;
Dunscombe, P. .
MEDICAL PHYSICS, 2012, 39 (12) :7272-7290
[10]   Can evidence-based medicine and clinical quality improvement learn from each other? [J].
Glasziou, Paul ;
Ogrinc, Greg ;
Goodman, Steve .
BMJ QUALITY & SAFETY, 2011, 20 :I13-I17