Implementation and operation of incident learning across a newly-created health system.

PURPOSE: The purpose of this work is to describe our experience launching an expanded incident learning system for patient safety and quality that takes into account aspects beyond therapeutic dose delivery, specifically imaging/simulation incidents, medical care incidents, and operational issues. METHODS: Our ILS was designed for a newly created health system comprised of a midsized academic hospital and two smaller community hospitals. The main design goal was to create a highly sensitive system to capture as much information throughout the department as possible. Reports were classified according to incidents and near misses involving therapeutic radiation, imaging/simulation, and patient care (not involving radiation), unsafe conditions, operational issues, and accolades/suggestions. Reports were analyzed according to impact on various steps in the process of care. Actions made in response to reports were assessed and characterized by intervention reliability. RESULTS: A total of 1125 reports were submitted in the first 23 months. For all three departments, therapeutic radiation incidents and near misses consisted of less than one-third of all reports submitted. For the midsized academic department, operational issues and unsafe conditions comprised the largest percentage of reports (70%). Although the majority of reports impacted steps related to the technical aspects of treatment (simulation, planning, and treatment delivery), 20% impacted other steps such as scheduling or clinic visits. More than 160 actions were performed in response to reports. Of these actions, 63 were quality improvement interventions to improve practices, while 97 were learning actions for raising awareness. CONCLUSIONS: We have developed an ILS that identifies issues related to the entire process of care delivery in radiation oncology, as evidenced by frequent and varied reported events. By identifying a broad spectrum of issues in a department, opportunities for improvement can be identified.

A case study of radiotherapy treatment for Dupuytren's contracture and Ledderhose disease.

Dupuytren's contracture (DC) and Ledderhose disease (LD) are benign conditions of the fascia in the hands and feet respectively, which result in contracture of the digits. Radiation therapy has been proven effective in treating early-stage DC and LD; however, the problem is that there is a paucity of literature regarding radiation therapy treatment set-up for Dupuytren's and Ledderhose patients. The purpose of this case study was to demonstrate treatment set-up considerations of 6 and 9 MeV for DC and LD cases in radiotherapy (RT). Two patients were selected from the same cancer center, each diagnosed with DC and LD. Treatment plans were established utilizing a clinical set-up, electron dose tables, bolus, and target volumes delineated by the radiation oncologist. For each patient, the radiation oncologist prescribed 2 treatment courses of 300 cGy in 5 fractions per treatment site. The radiation oncologist determined the desired depth of treatment, through the palpation of the nodules, and used electron depth dose tables to determine the energy, isodose lines, and bolus thickness necessary to treat the lesions to the appropriate depth. Doses delivered were verified with metal oxide semiconductor field effect transistors (MOS-FET) in vivo on the first day of treatment for each course. In this case study, researchers demonstrated clinical set-up for 2 patients treated for both DC and LD. The clinical set-up considerations resulted in successful treatment delivery with minor, but acceptable, variations during treatment.