Journal article
Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres
Reports of practical oncology and radiotherapy, Vol.23(3), pp.220-227
05/2018
PMCID: PMC5948319
PMID: 29760597
Metrics
18 Record Views
UN Sustainable Development Goals (SDGs)
This output has contributed to the advancement of the following goals:
Source: InCites
Abstract
Aim
To develop and apply a clinical incident taxonomy for radiation therapy.
Background
Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability.
Methods and materials
A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011–2015. Incidents were managed locally, audited and feedback disseminated to all centres.
Results
Across the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified.
Conclusions
The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.
Details
- Title
- Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres
- Creators
- Stuart Greenham - Mid-North Coast Cancer Institute (Coffs Harbour, Australia)Stephen Manley - Northern New South Wales Cancer Institute (Lismore, Australia)Kirsty Turnbull - Mid-North Coast Cancer Institute (Coffs Harbour, Australia)Matthew Hoffmann - Mid-North Coast Cancer Institute (Port Macquarie, Australia)Amara Fonseca - Northern New South Wales Cancer Institute (Lismore, Australia)Justin Westhuyzen - Mid-North Coast Cancer Institute (Coffs Harbour, Australia)Andrew Last - Mid-North Coast Cancer Institute (Port Macquarie, Australia)Noel J. Aherne - University of New South WalesThomas P. Shakespeare - University of New South Wales
- Publication Details
- Reports of practical oncology and radiotherapy, Vol.23(3), pp.220-227
- Publisher
- Elsevier
- Number of pages
- 8
- Identifiers
- 991013097819702368
- Copyright
- © 2018 Published by Elsevier Sp. z o.o. on behalf of Greater Poland Cancer Centre.
- Academic Unit
- Coffs Harbour Campus Administration
- Language
- English
- Resource Type
- Journal article