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Incident Learning During the Early COVID-19 Pandemic

B Chera1*, K Kujundzic2, A Raldow3, J Olsen4, H Demoss5, S Weintraub6, B Salter7, S Evans8, (1) UNC at Chapel Hill, Morrisville, NC, (2) ASTRO, Arlington, VA, (3) UCLA, Los Angeles, CA, (4) Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, (5) Clarity PSO, Chicago, IL, (6) Southcoast Hospitals Group, Fall River, MA, (7) University of Utah, Salt Lake City, UT, (8) Yale University, New Haven, CT


PO-GePV-T-139 (Sunday, 7/25/2021)   [Eastern Time (GMT-4)]

Purpose: To assess the impact of the early COVID-19 pandemic on incident learning through evaluation of RO-ILS: Radiation Oncology Incident Learning System. The Radiation Oncology Healthcare Advisory Council hypothesized that the pandemic would impact participant engagement in reporting to the patient safety organization and the characteristics of reported events.

Methods: The RO-ILS database was queried for events reported pre-COVID (March 1, 2019 to July 31, 2019) and during early COVID (March 1, 2020 to July 31, 2020). Events were segregated based on practices in early COVID hotspot states as identified by the CDC (WA, CA, AZ, TX, FL, NY, NJ, CT, MA, PA, MD) and their reporting status (Top 5). Descriptive statistics were used to describe trends in reporting and differences in data elements pre-COVID and during-COVID.

Results: There was a 16% absolute reduction in event reporting during-COVID (n=1255) as compared to pre-COVID (n=1759). Practices located in COVID-hotspots had a 33% absolute reduction in reporting, while those not in hotspots had a 23% reduction. However, initial analysis did not identify drastic change in event classification. Amongst the Top 5 reporting practices, there was a 48% absolute reduction in incident reporting; of note, three of these practices did not report any events during-COVID. During-COVID, errors more often occurred and were discovered during treatment planning, regardless of hotspot status. Practices rated more events as moderate-severe during-COVID (25%) than pre COVID (18%). No appreciable difference was observed in the types of treatment techniques nor magnitude of dosimetric deviations pre-COVID and during-COVID.

Conclusion: Reporting to RO-ILS declined during the early COVID-19 pandemic, especially in hotspot areas. Three of the five top reporting practices that ceased reporting have since reported events after the analysis timeframe, suggesting the decline may be temporary. Stability in event classification suggests that practices continued to report a variety of events.

Funding Support, Disclosures, and Conflict of Interest: The Radiation Oncology Healthcare Advisory Council (RO-HAC), managed by Clarity PSO, provides subject-matter expertise, analyzes, interprets and reports on RO-ILS data. RO-HAC members receive an honorarium from program sponsors ASTRO or AAPM.


Not Applicable / None Entered.


IM/TH- Formal Quality Management Tools: Error taxonomies and incident reporting analyses

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