A nationwide investigation of radiation therapy event reporting-and-learning systems: Can standards be improved?. Issue 4 (November 2017) - Dowling, K.
Abstract: Introduction: Variation exists between event reporting-and-learning systems utilised in radiation therapy. Due to the impact of errors associated with this field of medicine, evidence-based and rigorous systems are imperative. The implementation of such systems facilitates the reactive enhancement of patient safety following an event. The purpose of this study was to evaluate Irish event reporting-and-learning procedures against the current literature using a developed evidence-based process map, and to propose recommendations as to how the national standard could be improved. Methods: Radiation Therapy Service Managers of all Irish radiation therapy institutions (n = 12) were invited to participate in an anonymous online questionnaire. Included in the questionnaire was a reporting-and-learning process map developed from evidence-based literature, which was used to assess the institution's practice through the use of vignettes. Frequency analysis of closed-ended questions and thematic analysis of open-ended questions was performed to assess the data. Results: A 91.7% response rate was achieved. The following areas were found to have the most variation with the evidence-based process map: event classification, external reporting, and dissemination of lessons-learned to a wider audience. Recommendations to standardise practice were made. Conclusion: Opportunities for improvement exist within event reporting-and-learning systems of Irish radiation therapy institutions and recommendations have been made on these. These findings can provide learning for other countries with similar reporting systems. Highlights: Variance in event classification taxonomy is observed across a variety of clinical scenarios. Consistency was observed in categorisation of the impact of an event. Improvements in the timing and the scope of event reporting are warranted. Sub-optimal practice of dissemination of lessons-learned to a wide audience was evident across institutions.