USING INCIDENT LEARNING IN RADIATION THERAPY: THE FIRST-HAND EXPERIENCE IN A LOW-INCOME SETTING USING CUTTING-EDGE TECHNOLOGY

Abstract

Objective: To explore the implementation of an incident learning system for quality management of radiotherapy in a low-income radiotherapy setting. Materials and Methods: An incident learning system was specifically designed using the human-centred design, the waterfall model was implemented for error identification and learning of individual incidents. The incidents that occurred in external beam radiotherapy for 8 years, were reported. Results and Discussion: A total of 122 incidents, 49 Near-misses and 28 non-conformance were identified with 4465 patients treated within the 8 years. The total average percentage of 2.73, 1.10, 0.63 and 4.46 were detected for incidents, near miss and non-conformance respectively. The average incident, near miss and non-conformance rate per 100 patients treated were 2.73, 1.10 and 0.63 respectively over the 8-years review period. The highest wrong total dose error of 79 occurred in the eighth year. Trend analysis identifies major improvements in clinical practice by measuring and analyzing patterns of incidents over time. The trending incident levels for each treatment site were in decreasing order of level 4, level 1, level 2, level 5, and level 3. Conclusion: Treatment status gave an overview of the quality of clinical decisions and implementation in the management of radiotherapy patients. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety. Recommendation: Future iterations, would improve the error tagging and solution recommendation parts, and extend the implementation all radiotherapy centres in the country.