Missing the Near Miss: Recognizing Valuable Learning Opportunities in Radiation Oncology

Area of Science:

• Medical Physics
• Radiation Oncology
• Patient Safety

Background:

• Near miss events in radiation oncology are crucial for learning without patient harm.
• Understanding different types of near misses, based on latent errors and enabling conditions, is key.
• Cognitive biases can affect how staff perceive and report these events.

Purpose of the Study:

• To define distinct types of near miss events in radiation oncology.
• To explore how radiation oncology staff perceive these different near miss types.
• To identify how these perceptions influence the recognition of events as learning opportunities.

Main Methods:

• Defined six near miss event types based on latent error and enabling conditions.
• Used a pacemaker case example to illustrate event types.
• Administered a survey to radiation oncology staff assessing event success and willingness to report.

Main Results:

• Ninety-five staff members completed the survey.
• Perceived success and willingness-to-report scores varied significantly by near miss type (P=.042 and P<.0001, respectively).
• 'Could have happened' events were rated less successful and reported more often than 'almost happened' events.

Conclusions:

• Cognitive biases influence the recognition and reporting of near miss events.
• Educating staff on near miss types can enhance their recognition.
• Engaging staff in quality improvement initiatives is vital for better event reporting.