Matthew B Spraker1, Robert Fain2, Olga Gopan3, Jing Zeng3, Matthew Nyflot3, Loucille Jordan3, Gabrielle Kane3, Eric Ford3. 1. Department of Radiation Oncology, University of Washington, Seattle, Washington. Electronic address: spraker@uw.edu. 2. School of Medicine, Oregon Health and Science University, Portland, Oregon. 3. Department of Radiation Oncology, University of Washington, Seattle, Washington.
Abstract
PURPOSE: Incident learning systems (ILSs) are a popular strategy for improving safety in radiation oncology (RO) clinics, but few reports focus on the causes of errors in RO. The goal of this study was to test a causal factor taxonomy developed in 2012 by the American Association of Physicists in Medicine and adopted for use in the RO: Incident Learning System (RO-ILS). METHODS AND MATERIALS: Three hundred event reports were randomly selected from an institutional ILS database and Safety in Radiation Oncology (SAFRON), an international ILS. The reports were split into 3 groups of 100 events each: low-risk institutional, high-risk institutional, and SAFRON. Three raters retrospectively analyzed each event for contributing factors using the American Association of Physicists in Medicine taxonomy. RESULTS: No events were described by a single causal factor (median, 7). The causal factor taxonomy was found to be applicable for all events, but 4 causal factors were not described in the taxonomy: linear accelerator failure (n = 3), hardware/equipment failure (n = 2), failure to follow through with a quality improvement intervention (n = 1), and workflow documentation was misleading (n = 1). The most common causal factor categories contributing to events were similar in all event types. The most common specific causal factor to contribute to events was a "slip causing physical error." Poor human factors engineering was the only causal factor found to contribute more frequently to high-risk institutional versus low-risk institutional events. CONCLUSIONS: The taxonomy in the study was found to be applicable for all events and may be useful in root cause analyses and future studies. Communication and human behaviors were the most common errors affecting all types of events. Poor human factors engineering was found to specifically contribute to high-risk more than low-risk institutional events, and may represent a strategy for reducing errors in all types of events.
PURPOSE: Incident learning systems (ILSs) are a popular strategy for improving safety in radiation oncology (RO) clinics, but few reports focus on the causes of errors in RO. The goal of this study was to test a causal factor taxonomy developed in 2012 by the American Association of Physicists in Medicine and adopted for use in the RO: Incident Learning System (RO-ILS). METHODS AND MATERIALS: Three hundred event reports were randomly selected from an institutional ILS database and Safety in Radiation Oncology (SAFRON), an international ILS. The reports were split into 3 groups of 100 events each: low-risk institutional, high-risk institutional, and SAFRON. Three raters retrospectively analyzed each event for contributing factors using the American Association of Physicists in Medicine taxonomy. RESULTS: No events were described by a single causal factor (median, 7). The causal factor taxonomy was found to be applicable for all events, but 4 causal factors were not described in the taxonomy: linear accelerator failure (n = 3), hardware/equipment failure (n = 2), failure to follow through with a quality improvement intervention (n = 1), and workflow documentation was misleading (n = 1). The most common causal factor categories contributing to events were similar in all event types. The most common specific causal factor to contribute to events was a "slip causing physical error." Poor human factors engineering was the only causal factor found to contribute more frequently to high-risk institutional versus low-risk institutional events. CONCLUSIONS: The taxonomy in the study was found to be applicable for all events and may be useful in root cause analyses and future studies. Communication and human behaviors were the most common errors affecting all types of events. Poor human factors engineering was found to specifically contribute to high-risk more than low-risk institutional events, and may represent a strategy for reducing errors in all types of events.
Authors: Eric Ford; Leigh Conroy; Lei Dong; Luis Fong de Los Santos; Anne Greener; Grace Gwe-Ya Kim; Jennifer Johnson; Perry Johnson; James G Mechalakos; Brian Napolitano; Stephanie Parker; Deborah Schofield; Koren Smith; Ellen Yorke; Michelle Wells Journal: Med Phys Date: 2020-04-15 Impact factor: 4.071
Authors: Babiche E J M Driesen; Mees Baartmans; Hanneke Merten; René Otten; Camilla Walker; Prabath W B Nanayakkara; Cordula Wagner Journal: J Patient Saf Date: 2021-10-13 Impact factor: 2.243