Impact of implementing an electronic radiation oncology-specific in-house incident learning system.
PD-0662
Abstract
Impact of implementing an electronic radiation oncology-specific in-house incident learning system.
Authors: Laura Adamson1,2, Krystle Crouch3, Rachael Beldham-Collins4, Jonathan Sykes4,2, David Thwaites2,4
1Crown Princess Mary Cancer Centre, Radiation Thearpy, Sydney, Australia; 2School of Physics, Institute of Medical Physics, University of Sydney, School of Physics, Sydney, Australia; 3Crown Princess Mary Cancer Centre, Radiation Therapy , Sydney, Australia; 4Crown Princess Mary Cancer Centre, Radiation Therapy, Sydney, Australia
Show Affiliations
Hide Affiliations
Purpose or Objective
Incident learning systems
(ILS) provide a formalised framework for incident reporting, analysis, data
visualisation, feedback, and learning. Robust ILS can identify quality improvement
(QI) areas and strengthen quality assurance (QA) pathways. A QI project to
develop a digital in-house radiation oncology (RO) ILS was undertaken, with
success demonstrated in the first 12 months of use.
Material and Methods
A needs assessment was performed in 2019, including an
in-house survey on staff knowledge and understanding of current incident
reporting methods, ILS and the safety culture climate. Additionally, relevant
literature was reviewed. From this, the QI team designed and implemented an electronic reporting system
to suit departmental needs and tested its impact at 12 months via a follow-up
survey.
Results
The needs assessment identified that the paper-based ILS in
use required improvement. Barriers to reporting were perceived by 67% of
respondents and most staff (75%) preferred an electronic in-house system. The state-wide hospital-level reporting
system did not meet the detailed needs of RO. Therefore, a customised electronic
departmental-level reporting system was developed on the Varian AriaTM oncology information system platform. It supported actual incident
reporting and lower level reporting (e.g.,
near miss, protocol non-compliance) to increase capacity for learning and QA/QI
guidance. It works in parallel with the
state-wide system to ensure clinical governance of higher-level reports being reported
correctly. The new ILS includes a dedicated triage team, ensuring accurate data
capture and rapid coordination of further analysis/escalation when required.
Increased data accuracy has been demonstrated in the new ILS, with easy access
for all staff to see reports. Clear data visualisation tools are used in
Microsoft ExcelTM and Power BITM. The triage team provides
increased communication and rapid feedback to staff and management when needed
for urgent QI, education or reminders. Monthly meetings to discuss learning opportunities
and potential QI ideas are now open to all, rather than the previous separate senior
staff meetings. Follow up survey results after 12-months of system use showed: decreased perception of barriers (from 67% to
57%); increased participation in reporting (48% to 70% of respondents having been
involved); increased perception of a no-blame culture (49% to 58%); and
increased ability to learn from reported incidents (49% to 86%).
Conclusion
The creation
of a customised electronic ILS, suited to RO department needs, addressed issues
with the previous system. Overall, the new ILS had a positive impact and adapted
rapidly when Covid-19 impacted the standard hospital workflow. Increased feedback loops to the RO team are
well integrated into the new ILS. The move to electronic an ILS has enabled easy
access to data that highlight weaknesses in processes and protocols and has
supported continuing QI initiatives.