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Incident learning in radiation oncology: A review
Author(s) -
Ford Eric C.,
Evans Suzanne B.
Publication year - 2018
Publication title -
medical physics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.473
H-Index - 180
eISSN - 2473-4209
pISSN - 0094-2405
DOI - 10.1002/mp.12800
Subject(s) - context (archaeology) , accreditation , radiation oncology , patient safety , medicine , medical education , psychology , health care , radiation therapy , political science , paleontology , law , biology
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems ( ILS ) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS , challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.