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Session: Therapy: Patient Safety and Quality Improvement [Return to Session]

Retrospective Evaluation of Incident Learning Data in the Six Months Prior to and During COVID-19

J Crosby*, D Jacqmin, University of Wisconsin, Madison, WI


TU-IePD-TRACK 6-4 (Tuesday, 7/27/2021) 12:30 PM - 1:00 PM [Eastern Time (GMT-4)]

Purpose: The COVID-19 pandemic caused many changes in our clinic, including variable patient volume, a shift towards hypofractionation, and changes in on-site staff availability. This work sought to retrospectively evaluate incident learning data before and after our state declared a public health emergency due to COVID-19.

Methods: Our clinic has been operating an electronic incident reporting system since January 2017. All staff members can voluntarily report patient safety incidents and other clinical issues. The reports submitted during the six months pre- and post-March 13th, 2020, were reviewed and analyzed for trends that could be associated with clinical changes due to COVID-19. The reports (n=475) were categorized with respect to event classification (incident, near miss, etc.), whether a dosimetric change was required, anatomical site, the process step where incidents occurred and were discovered, the role of the reporter, and the type of intervention. Within each category, the number and distribution of reports before and during COVID-19 were compared to identify changes over time.

Results: The overall number of reports decreased by 19% (262 to 213) in the 6 months following March 13th. The event classifications that had the greatest decrease were “near miss” (-36%) and “operational/process improvement” (-19%). Of all team members, incident reporting by physicists remained the closest to baseline (-7%). While the overall number of reports submitted decreased, the number that involved a plan revision increased by 18%. The proportion of reports addressed with a quality improvement intervention increased during COVID-19 from 45% to 63%. In direct response to the pandemic, a change in the operational model for physician coverage was implemented.

Conclusion: Patterns of incident reporting changed during COVID-19, with fewer reports being submitted for low-severity issues. This change may be attributable to staff effort being redirected to respond to COVID-19-associated clinical changes.



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