The management of radiation treatment error through incident learning

To assess efficacy of an incident learning system in the management of error in radiation treatment.

We report an incident learning system implementation customized for radiation therapy where any "unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment" is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin.

Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p<0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p<0.001).

Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements.