Implementation of a radiation oncology incident learning system in a limited resource setting: risk analysis and safety culture.

Abstract

Few reports address the use of incident learning systems (ILS) in low- and middle-income countries (LMICs). We hypothesize that ILS can support quality improvement (QI) needs in an LMIC clinic, and that a commitment to QI can overcome perceived barriers to ILS uptake. A preliminary survey assessing safety culture and perceived barriers to ILS use was distributed to all clinical staff at a radiation oncology clinic in sub-Saharan Africa. An ILS was implemented based on the International Atomic Energy Agency taxonomy. After seven months, ILS reports were analyzed by type, clinic area, clinical role, and origin. Quality control quantification (QCQ) was used to determine the QA intervention most likely to prevent or detect each error. An interdisciplinary team of clinicians used failure modes and effects analysis (FMEA) to rank 23 representative failure modes by risk priority number (RPN). Survey responses indicated that "concern on the part of the reporter about their reputation or the effects of reporting a colleague" was a barrier to incident reporting. Despite this, the ILS collected eighty-four reports throughout the seven-month accrual period. Most were classified as near-misses (32, 38%). Although most reports were entered from the LINAC control rooms (41, 48.8%), treatment planning was the most common origin of errors (28, 33.3%). The most frequently identified QA intervention that would have prevented errors was a comprehensive physics plan check (29 reports). The highest-RPN failure mode was associated with a treatment delivery error related to the oncology information system (OIS). ILS reports indicate that QI needs center on treatment planning and technical plan review, as well as OIS implementation. This study, one of the few to explore the use of ILS in the LMIC setting, illustrates how a commitment to QI can overcome perceived barriers to ILS use.