Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

摘要

Fifteen years of reported incidents were reviewed to provide insight into the effectiveness of an Incident Learning System (ISL). The actual error rate over the 15 years was 1.3 reported errors per 1000 treatment attendances. Incidents were reviewed using a Mann-Whitney U Test. The average number of incidents per year and the number of incidents per thousand attendances declined over time. Two seven-year periods were considered for analysis and the average for the first period (2005–2011) was 6 reported incidents per 1000 attendances compared to 2 incidents for the later period (2012–2018), p < 0.05. SAC 1 and SAC 2 errors have reduced over time and the reduction could be attributed to the quality assurance aspect of IGRT where the incident is identified prior to treatment delivery rather than after, reducing the severity of any potential incidents. The reasoning behind overall reduction in incident reporting over time is unclear but may be associated to quality and technology initiatives, issues with the ISL itself or a change in the staff reporting culture.