Steele EM, Whitmill MA, Amos A, Oaks ZA, McGurk R, Dance MJ, Mazur L, Weiner AA, Marks LB, Chera BS, Sud S. Incident Learning in an Academic Radiation Oncology Practice during the COVID Era.
Int J Radiat Oncol Biol Phys 2023;
117:e440-e441. [PMID:
37785430 DOI:
10.1016/j.ijrobp.2023.06.1617]
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Abstract
PURPOSE/OBJECTIVE(S)
Incident learning is key to developing and maintaining quality and safety in healthcare. We aimed to characterize acute and sustained changes in incident submissions, point of incident origin/detection, severity and associated contributing factors during the COVID-19 pandemic.
HYPOTHESIS
The frequency and pattern of incident origin/detection were changed by altered workflows in response to COVID-19.
MATERIALS/METHODS
Events from our experienced incident learning system were analyzed between three 12-month intervals: pre-COVID (March 1, 2019 - February 29, 2020), early-COVID (March 1, 2020 - February 28, 2021), and late-COVID (March 1, 2021 - February 28, 2022). In addition to review by the department quality and safety committee, at least two physicians reviewed all incidents. Using descriptive statistics and chi-square test as applicable, we compared the reporting rates, incident severity, contributing factors, points of origin/ detection according to time the pre-specified time intervals prior to and during COVID.
RESULTS
See Table.
CONCLUSION
During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. The number of incidents per patient increased with early-COVID altered workflows. This suggests that existing quality and safety checks were effective during early-COVID. The point of incident origin was similar across time periods. During early-COVID, the point of incident detection shifted to earlier points in the care pathway (e.g., pre-RT chart checks vs chart checks during RT), p<0.001. During late-COVID, as clinical workflows adapted, the point of detection shifted to later in the care pathway consistent with pre-COVID patterns. During COVID, workload was implicated in fewer incidents (in the setting of reduced treatment volumes), while communication and hand-offs were more frequently cited as contributing factors (in the setting of remote work). Our data supports the utility of consistent standards, minimizing inter-provider variations and maintaining robust quality and safety checks to optimize communication and safe patient care in radiation oncology.
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