Incident Learning in an Academic Radiation Oncology Practice during the COVID Era

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.

The Need for Patience When Making Operational Changes to Address Quality

PURPOSE/OBJECTIVE(S)

There is increasing recognition in the value of systematically addressing operational issues to improve quality. However, the time necessary for these initiatives has not been well described. Here we report the time necessary to implement meaningful operational changes based on our institutional incident reporting system.

MATERIALS/METHODS

Our department has a robust quality improvement/assurance program where all team members are encouraged to report operational challenges through our "Good Catch Program". A multidisciplinary committee composed of MDs, physicists, dosimetrists, RTTs, RNs, administrators, and industrial engineers meets weekly to review new Good Catches and prior unresolved Good Catches. Each Good Catch was assigned a "Champion" to oversee responses and lead subsequent initiatives. The software tracked when a Good Catch is submitted, each time a note is added (reflecting an individual's comment or summary of group discussion), and when it is "closed". Good Catch closure occurred upon implementation of a change in workflow, development of a new policy, or decision to take no action. In cases where a change in workflow or policy was the consensus decision of the committee, the Good Catch was kept open and re-reviewed at subsequent weekly meetings until a new workflow was in place and relevant teams were onboarded.

RESULTS

From Jan 2015 - Dec 2022, 2748 Good Catches were reported (see Table). Most Good Catches were discussed at only one weekly multidisciplinary committee meeting and closed within 7 days of reporting (69%). For the 854 Good Catches that took >1 week to close, the median time to closure was 16 days (range 7-588 days). In general, the number of notes was higher for Good Catches that took longer to close; however, some Good Catches that closed rapidly had more than 10 notes in a short period of time and other Good Catches with lengthy time to closure had minimal resulting documentation (see Table). Most Good Catches were assigned a Champion who was an MD, Physicist, or RTT, and there was no significant difference in Champion assignments for those good catches that closed quickly (< 8 days) and those that had a longer duration to closure.

CONCLUSION

The majority of operational Good Catches are resolved quickly; speaking to the value of regular weekly multidisciplinary meetings. However, many operational issues require multiple discussion over many weeks and emphasizes that such efforts are challenging and require patience, dedication, and commitment to implement changes in workflow.

Assessing the Sustainability of Initiatives Aimed to Enhance Patient Safety Culture: A > 10-year Experience with Multifaceted Interventions

PURPOSE/OBJECTIVE(S)

Culture is a key factor in maintaining high-quality care. We have instituted a series of mutually-reinforcing initiatives aimed to improve operations, and patient and staff safety. We herein review the impact of these initiatives on our Patient Safety Culture over 14 years. We hypothesize that these initiatives can lead to sustained improvements in Culture.

MATERIALS/METHODS

In ≈ 2009, our department, with help of dedicated quality improvement coaches from our internal Division of Healthcare Engineering (with knowledge of Lean-Six Sigma and High Reliability methods and tools), instituted (and largely sustained) initiatives aimed to improve our operations, and to improve patient/staff safety; including: (a) daily multidisciplinary team huddles, (b) daily pre-planning/treatment peer review, (c) a robust Incident Learning System, (d) weekly meetings to review reported incidents, (e) monthly department-wide meetings to review the highlights from the weekly incident review meetings, (f) celebration/recognitions for staff participation and (g) leader Gemba walks. Culture was quantitatively assessed via the AHRQ (Agency for Healthcare Research and Quality) Patient Safety Culture Survey (with 51 questions) which was sent to the department every two years (2021 was skipped due to Covid). Changes in the summary survey results over time were assessed using 2-tailed chi-square.

RESULTS

Within 2-4 years of starting of our initiatives, there was an increase in the number of survey respondents, and an increase in the % of favorable responses (vs. pre-initiative data from 2009), for most comparisons (see Table with representative data). The % favorable responses plateaued in ≈ 2013-2015, and there was a non-significant decline in % favorable responses in later years (vs. the high scores in 2015).

CONCLUSION

A series of mutually reinforcing initiatives aimed to improve operations, and to improve patient/staff safety, can lead to improvements in Patient Safety Culture; and these improvements can be largely sustained over time. Some of the modest non-significant decline in later years may reflect staff changes, fatigue, increasing practice complexity, financial pressures, and/or Covid-related issues (in the 2022 survey). This speaks to the importance of maintaining quality/safety initiatives through transitions in leadership, staff and external stressors.

1458 Compliance of Abdominal X-ray Requesting with iRefer Guidelines in CDDFT

Aim

100% of Abdominal x-ray (AXR) requests in the trust should be compliant with iRefer guidelines. Therefore, with this audit we hope to evaluate the compliance of our hospitals with said guidelines.

Method

This audit was retrospective with AXRs taken between 23 – 29th of November 2020 being analysed for compliance creating our first loop. On the 1st of December we placed our intervention. This came in the form of educational posters in the four areas that request the majority of AXRs. Following this, a further weeks’ worth of AXRs were assessed for compliance between 2nd – 8th of December 2020.

Results

Between 23-29/11/20 there were 67 AXRs requested. Eight of these were excluded according to our exclusion criteria, leaving a total of 59 AXRs to be assessed. After reviewing the request cards for these AXRs, 17 were non-compliant (28.8%). Following the intervention, AXR requests were re-audited. Between 2-8/12/20 there were 69 AXRs requested. Six were excluded leaving a total of 63 AXRs to be assessed. After review, 22 were non-compliant (34.9%)

Conclusions

In both loops of this audit, the standard of 100% compliance with iRefer guidelines was not met. There was a high percentage of non-compliance in both loops with a rate of 28.8% and 34.9% respectively – a decrease in compliance. One possible reason to account for this was due the changeover of Junior Doctors within the trust on 2/12/20. Our interventional posters were placed in only half of the Trusts hospitals which may also account for the decrease in compliance.

Individual differences in cognitive planning on the Tower of Hanoi task: neuropsychological maturity or measurement error?

The Tower of Hanoi (ToH) task was given to 238 children aged from 7 to 15 years, and 20 adults. Individual variation within an age band was substantial. ToH score did not correlate significantly with Verbal IQ, nor with ability to inhibit a prepotent response. We readministered the ToH to 45 children after 30 to 40 days. The test-retest correlation of .5 is low in relation to accepted psychometric standards, though at least as high as reliability of the related Tower of London (ToL) in adults. The reasons for low reliability remain unclear: task novelty did not seem to be involved, as children did not improve on retest. We conclude that it is not safe to use this test to index integrity or maturation of underlying neurological systems in children. We compared our results with three published studies using the ToL with children, and found similar levels of performance on problems involving the same number of moves. Another study using automated ToL obtained much poorer scores, suggesting that computerised presentation may impair children's performance.

Prevalence of complementary therapy use by women with breast cancer. A population-based survey

The study measured the prevalence and costs of complementary therapy use by women diagnosed with breast cancer in the South Thames NHS region. A postal questionnaire was sent to a sample of 1023 women from the Thames Cancer Registry who had been diagnosed with breast cancer in the previous 7 years. Just over a fifth (22.4%) had consulted a complementary practitioner in the previous 12 months. Almost one third (31.5%) had done so since diagnosis. Almost pound17000 had been spent on visits in the previous year. The women using complementary medicine after diagnosis were slightly younger, more educated and more likely to have used complementary medicine before their diagnosis than non-complementary medicine users. In conclusion, significant numbers of women are visiting complementary therapists for health reasons following a breast cancer diagnosis. The out of pocket costs per user, with notable exceptions, are modest. Use of practitioners of complementary therapies following diagnosis is a significant and possibly growing phenomenon.

Evidence from Turner's syndrome of an imprinted X-linked locus affecting cognitive function

Turner's syndrome is a sporadic disorder of human females in which all or part of one X chromosome is deleted. Intelligence is usually normal but social adjustment problems are common. Here we report a study of 80 females with Turner's syndrome and a single X chromosome, in 55 of which the X was maternally derived (45,X[m]) and in 25 it was of paternal origin (45,X[p]). Members of the 45,X[p] group were significantly better adjusted, with superior verbal and higher-order executive function skills, which mediate social interactions. Our observations suggest that there is a genetic locus for social cognition, which is imprinted and is not expressed from the maternally derived X chromosome. Neuropsychological and molecular investigations of eight females with partial deletions of the short arm of the X chromosome indicate that the putative imprinted locus escapes X-inactivation, and probably lies on Xq or close to the centromere on Xp. If expressed only from the X chromosome of paternal origin, the existence of this locus could explain why 46,XY males (whose single X chromosome is maternal) are more vulnerable to developmental disorders of language and social cognition, such as autism, than are 46,XX females.