The management of radiation treatment error through incident learning.

PURPOSE: To assess efficacy of an incident learning system in the management of error in radiation treatment. MATERIALS AND METHODS: We report an incident learning system implementation customized for radiation therapy where any "unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment" is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin. RESULTS: Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p<0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p<0.001). CONCLUSIONS: Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements.

The standardization of radiation skin care in British Columbia: a collaborative approach.

PURPOSE/OBJECTIVES: To develop evidence-based practice guidelines for and standardize the care of radiation skin reactions. DATA SOURCES: Peer-reviewed scientific journals and texts and a survey of the guidelines in use at leading cancer treatment facilities in Canada, the United States, the United Kingdom, and Australia. DATA SYNTHESIS: A formal reference document with recommended guidelines was developed. Consensus was obtained from all relevant disciplines, and the guidelines were implemented successfully into practice. CONCLUSIONS: The document introduced a major change in practice from the maintenance of a dry radiation treatment area to the promotion of skin cleanliness and hydration, as well as the adoption of the principles of moist wound healing. Annual review indicated that dissemination of (94%) and compliance with (78%) the guidelines were good. IMPLICATIONS FOR NURSING: The process to develop, obtain consensus for, and implement evidence-based practice guidelines was an exemplary demonstration of teamwork and interdisciplinary collaboration.