Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada.
J Appl Clin Med Phys. 2022 Nov;23(11):e13742. doi: 10.1002/acm2.13742. Epub 2022 Aug 6.
The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS)-a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID-19 pandemic.
In this study, we analyzed the number and type of ILS submissions pre- and postpandemic precautions to assess the impact of COVID-19-related workflow changes.
ILS data was collected over six one-year time periods between March 2016 and March 2021. For all time periods, the number of ILS submissions were counted. Each ILS submission was analyzed for the specific treatment domain from which it arose and its root cause, explaining the impetus for the error or near miss.
Since the onset of COVID-19-related workflow changes, the total number of ILS submissions have reduced by approximately 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to prepandemic data. There was also an increase in the proportion of "treatment planning" ILS submissions and a 50% reduction in the proportion of "decision to treat" ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to "poor, incomplete, or unclear documentation" during the pandemic year.
COVID-19 workflow changes were associated with fewer ILS submissions, but a relative increase in submissions stemming from poor documentation and communication. It is imperative to analyze ILS submission data, particularly in a changing work environment, as it highlights the potential and realized mistakes that impact patient and staff safety.
渥太华医院的放射肿瘤学项目维护着事件学习系统（ILS）-一个质量保证计划，该计划包括来自放射治疗所有主要领域的错误和险些发生的报告提交。2020 年 3 月，该部门采用了工作流程变更，以优化 COVID-19 大流行期间患者和医务人员的安全。
在这项研究中，我们分析了 ILS 提交的数量和类型，以评估 COVID-19 相关工作流程变更的影响。
ILS 数据是在 2016 年 3 月至 2021 年 3 月的六个一年时间段内收集的。在所有时间段内，都计算了 ILS 提交的数量。分析了每个 ILS 提交的特定治疗领域及其根本原因，解释了错误或险些发生的原因。
自 COVID-19 相关工作流程变更以来，ILS 提交的总数减少了约 25%。同样，与大流行前的数据相比，每疗程的 ILS 提交数量减少了 30%。“治疗计划”的 ILS 提交比例也有所增加，而“治疗决策”的 ILS 提交比例则比前几年减少了 50%。根本原因分析显示，在大流行期间，由于“记录不佳、不完整或不清楚”而导致的事件更多。
COVID-19 工作流程变更与 ILS 提交数量减少有关，但与较差的文档和沟通有关的提交数量相对增加。分析 ILS 提交数据至关重要，尤其是在不断变化的工作环境中，因为它突出了影响患者和员工安全的潜在和已实现的错误。
