Department of Radiation Oncology, University of Washington, Seattle, WA, 98195, USA.
Department of Radiation Oncology, Yale University, New Haven, CT, 06510, USA.
Med Phys. 2018 May;45(5):e100-e119. doi: 10.1002/mp.12800. Epub 2018 Apr 11.
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.
事件学习是医疗保健安全和质量保障的关键组成部分。其应用已经得到专业学会建议、法规和认证以及客观证据的充分支持。在放射肿瘤学领域，事件学习系统（ILS）受到了广泛关注，自 2010 年以来已经有超过 40 篇相关出版物。本文旨在对放射肿瘤学中的 ILS 进行全面综述，包括其历史和现有文献的总结、命名法和分类方案、机构层面 ILS 的运行方面，包括事件处理和根本原因分析，以及用于共享学习的国家和国际 ILS。本文还讨论了 ILS 背景下患者安全的核心原则，包括错误的系统观、安全文化以及认知偏差等影响因素。最后，本文还讨论了医疗差错披露和第二受害者综合征的相关话题。尽管 ILS 在快速发展和理解方面取得了进展，但在将 ILS 应用于放射肿瘤学领域时仍存在挑战。本综述可为进一步的工作提供基础。
