RESUMEN
PURPOSE: In 2011, the Canadian Partnership for Quality Radiotherapy developed guidelines for quality improvement. In the same year, a large academic cancer centre initiated a program of root cause analysis (RCA) and incident learning for major incidents. RCAs were performed on seven incidents; more than 40 action items were developed with the intent to prevent these incidents from recurring. The aim of this study was to determine the efficacy of implementation of the six action items, evaluate radiation therapists' (RTTs') awareness of these new action items, and determine whether communication among staff members was satisfactory. METHODS AND MATERIALS: The study consisted of two components. Part one examined four action items using a questionnaire distributed to all RTTs at the cancer centre. Part two examined two action items by auditing the radiation treatment software, MOSAIQ. RESULTS: Staff communication and RTTs' awareness of the action items ranged from 71% to 98%. For the first four action items, although most RTTs were aware of them, only 40%-70% of RTTs always or often used these action items and considered them effective. The fifth action item, implementation of the new breast tolerance setting, had 51% more overrides after implementation. Further investigation indicated only 40% of the tangent breast setups had new tolerance settings applied. CONCLUSIONS: Communication plays an important role in the dissemination and application of interventions identified from an RCA. A standardized route of communication is required to ensure that all RTTs fully understand an action item. A follow-up program and continuous monitoring of the action items are key to an effective RCA program.
