The Boy Who Cried Wolf: The Perceptions of Reporting Near Misses in the Radiation Therapy Program

Abstract

This study was conducted to determine the current state of reporting near misses and the effectiveness of the reporting system within the radiation therapy program at our institution. A literature review was performed to guide the synthesis of interview questions in evaluating the state of reporting near misses at our institution. One-on- one semi-structured interviews were conducted with seventeen radiation therapists regarding their perceptions of near misses and their opinions of the reporting systems. The interviews were conducted with the primary investigator and participant, audiotaped, and passed through a mixer to ensure anonymity. Each interview was transcribed and the data were analyzed using a thematic analysis. To increase validity, a co-investigator conducted an independent blinded thematic analysis. The themes which were present and reoccurring between participants were gathered and discussed. The perception of interviewees is that reporting near misses is integral to a good practice; awareness, prevention of future near misses, correction and improvement of QA were listed as reasons that near misses should be reported. The data suggest participants understand that near misses and errors may occur at any point of the planning to treatment process. Additionally, the results demonstrated recurrent barriers from reporting near misses, such as the lack of impact, the format of the reporting system, lack of time, and fear from others. Participants concluded that the current monthly staff meetings with discussion of error reports were effective and helpful. However, participants felt that it could be improved in various ways, such as changes in the meeting format, incorporation of written records, and immediate notifications. The results of this study emphasized the importance of reporting near misses within the radiation therapy program at a large, academic, Canadian Cancer Centre. In addition, the participants acknowledged potential barriers that may prevent other radiation therapists from reporting near misses. Future studies should investigate various ways to eliminate the barriers of reporting near misses and better educate radiation therapists on how reporting and discussing near misses can improve quality assurance programs.