Implementation of an On-line Incident Learning System in a Radiation Medicine Program

Abstract

Incident learning is an important aspect of quality improvement in health care. This work describes the implementation and customization of the on-line Safety Incident Learning System (SaILS) at our centre. SaILS was developed at the Ottawa Hospital and further refined at the McGill University Health Centre. Prior to implementation of SaILS at our centre, incidents were reported using a soft copy form that was circulated via email to the incident investigation team. Investigation findings were entered into the same soft copy form and summaries transcribed manually to a spreadsheet for further analysis. Objectives of this work were to streamline incident reporting and investigation and to align the language with which incidents are described with the National System for Incident Reporting – Radiation Therapy (NSIR-RT) taxonomy. A process map was developed to illustrate the many steps and handoffs of the existing incident learning process. The McGill University SaILS user-code was installed locally and a new work-flow was developed using various SaILS functions. The program was customized to ensure that all necessary steps and handoffs were handled appropriately and supplementary applications, such as the user dashboard and task assignment, were added. Tutorials were provided to radiation medicine program team members to examine the new process map and provide an overview of SaILS functionality. Implementation of SaILS is anticipated to improve the efficiency of incident reporting and learning. Incident investigation team members will be able to view the progress of incident investigations within the SaILS environment and the time required to track the incident investigation progress will be reduced. It will no longer be required to transcribe an incident summary to a spreadsheet as SaILS is enabled to perform the required analytics. File management needs are also reduced as there is a single incident record in SaILS rather than multiple soft copies circulated via email for each incident. The transition to this new system will be challenging to staff as the process and the language used to describe incidents have changed. Implementation of an on-line incident learning system using the NSIR-RT taxonomy will streamline incident reporting and investigation. Future work will include automated submission of the reports to the NSIR-RT database as required by Cancer Care Ontario.