A Practice-based Taxonomy for Radiation Treatment Errors.

Area of Science:

• Medical Physics
• Radiation Oncology
• Patient Safety

Background:

• Lack of a standardized language for incident classification hinders knowledge sharing in radiotherapy.
• This limitation impacts learning and improvement within and between healthcare organizations.

Purpose of the Study:

• To develop a clinically relevant and standardized taxonomy for classifying radiotherapy errors.
• To facilitate improved incident reporting and knowledge sharing in radiation oncology.

Main Methods:

• A multicenter, prospective study involving three phases: taxonomy development, iterative revision using incident data, and face validity testing with practitioners.
• Utilized the World Health Organization Conceptual Framework for the International Classification for Patient Safety.

Main Results:

• The developed taxonomy includes seven classes: incident nature, impact, type, origin, discovery, contributing factors, and preventative strategies.
• Initial face validity testing showed low agreement, but revisions based on feedback led to high interobserver agreement (70%-93%) in the second test.

Conclusions:

• An iterative development process resulted in a workable, multidimensional taxonomy for radiotherapy incidents.
• The taxonomy is scalable and can be implemented in incident databases to enhance learning across institutions.