Sci-Thurs PM: Delivery-05: One year of learning from incidents.

The aim of this study is to quantify the effect of an incident learning system in radiation therapy. The system is designed to detect all occurrences of "an unwanted or unexpected change from a normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment". Our application to radiation therapy defines 5 incident types, four levels of severity and four work domains where errors discovered during routine quality assurance within each domain were not classified as incidents. During 2007, we recorded, corrected, investigated, determined root cause and learned from 657 incidents. The vast majority of these incidents were classified as potential minor clinical incidents having little or no impact on patient treatment. The value of the system lies in the application of the learning portion of the investigation. We demonstrated a dramatic reduction in the rate of more severe incidents by the implementation of several simple tools. Our results also show a reduction of incidents on accelerators treating essentially a single disease site. The only treatment unit treating with both image guidance and intensity modulation recorded the fewest incidents while the cobalt unit with the least technological assistance recorded three times the average treatment unit incidents with a higher severity. Additionally, although the rate of incidents at the point of treatment delivery was low, the impact of those incidents was substantially higher than that of incidents originating during treatment planning. This system has proven to be a powerful program management tool.