AAPM task group report 288: Recommendations for guiding radiotherapy event narratives

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Risk Management

Background:

• Incident reporting and learning systems (IRLS) are crucial for identifying systemic vulnerabilities.
• The effectiveness of IRLS depends on the clarity and organization of incident narratives.
• Poorly written narratives hinder the ability to learn from incidents and improve quality.

Purpose of the Study:

• To provide guidance for drafting effective incident narratives within IRLS.
• To enhance the quality of information captured in incident reports for better learning.
• To assist organizations and individuals in creating useful narratives for IRLS.

Main Methods:

• The report offers recommendations for structuring incident narratives.
• It suggests including a brief synopsis, chronological sequence of events, and specific headings.
• Guidance is provided on supplementary data collection and information to exclude (e.g., PHI, blame).

Main Results:

• Effective narratives should include a chronological sequence of events and actions by role.
• Suggested headings guide reporters through key aspects of the incident.
• Excluding patient health information, conjecture, blame, and jargon improves narrative clarity.

Conclusions:

• Well-drafted incident narratives are essential for maximizing the learning potential of IRLS.
• Implementing structured guidance improves the quality and utility of incident reporting.
• Clear, concise, and objective narratives contribute to systemic vulnerability identification and quality enhancement.