Near misses reporting: effective tool for safety culture shift in a Radiation Oncology Department

ABSTRACT

Purpose or Objective To share the lessons learned from 2 years monitoring and analysis of near misses in a RO department. Emphasis will be put on the changes in the quality and safety culture amongst the different professional groups in the department. Materials and Methods Ten years ago a general-purpose voluntary Incident Learning System (ILS) was implemente, however few incidents (5 per year) were reported by the RO staff. Two years ago, a structured RO voluntary ILS based on RedCap and linked to a QR code was implemented to facilitate near misses and incident reporting. A multidisciplinary committee, meeting twice a month, to monitor the ILS was created. Bimonthly feedback to the staff was given. An ILS database temporal analysis focusing on the different staff members reporting and number of events reported on each treatment process station was performed. On January 2021, a survey to all staff to assess their adherence to the ILS and their perception its relevance on safety culture was sent. Results 3,315 events were reported;92.5% near misses and 7.5% incidents. Lack of evaluating patient specific QA (40% of all incidents) followed by delays in the treatment initiation (23%) and misadministration of the treatment (8.5%) were the most frequent incidents. The temporal trends on number of reported events, incidents andnumber of events per station are shown on fig. 1 and 2. We detected that while the number of events reported at the treatment unit was constant the number of events reported on plan and treatment chart evaluation has decreased considerably over the last 6 months. This could be caused as a result of an in-depth study, by requirement of the dosimetrists, on the most frequent events during treatment planning resulting on a reduction of events. On the last 3 months a relaxation of MP in reporting has also been detected with an increase of events reaching the treatment unit. The number of personnel reporting was around 30 (SD 9) on the studied time period. A reduction on reported events during the first COVID wave, attributed to a reduction of on-site staff and disruption of feedback was observed. 50/63 staff members answered the survey. 90% agreed that ILS is an important tool for the treatments safety , 60% that contributed improve safety culture, 82% agreed on the importance of regular feedback. Only 10 respondents had never reported an adverse event (0 administrative staff, 1/3 of RO and 1/2 of nurses). The most frequent causes for non-reporting were;forget to report (32%), lack of time (20%), not sure if reportable (15%), fear to consequences (5%). 26/50 had detected an adverse event but only 15 had reported it.