Did COVID-19 Have an Impact on Incident Leaning? Implications for Patient Safety.

Abstract

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. The purpose of this study was to analyze the number and type of ILS submissions pre- and post-pandemic precautions to assess the impact of COVID-19-related workflow changes. ILS data was collected over seven one-year time periods between March 2016 and February 2023, where COVID-19-related workflow changes were initiated March 2020, and lifted in March 2022. All incidents in the system were previously investigated as per clinical practice. Incidents were analyzed for the number of reports submitted and number of actual versus potential incidents as compared to previous years. Origin and detection domains were tabulated for each period under consideration, as were the root causes of the incidents. With the onset of COVID-19-related workflow changes, the total number of ILS submissions were reduced by 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to pre-pandemic 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 years. In the most recent year, as COVID-19 workflow changes have eased, the total number of ILS submissions has returned to the pre-pandemic baseline average. During the pandemic years, workflow and staffing changes were associated with a decrease in the number of ILS submissions indicating less engagement with a vital component of quality assurance and therefore patient safety. In addition, significant changes observed regarding the types of submissions reported during the pandemic years are reflective of the unique challenges encountered during pandemic precautions. Continued engagement with ILS reporting is essential to the continued safety of the radiation oncology program, particularly during the dynamic COVID-19 pandemic or other periods of rapid change within a program.