Deviation from Standard Practice: A Novel Categorization within the Incident Reporting and Learning System

Incident reporting and learning are key components of a quality management system. In May 2013, a Radiation Treatment Quality and Safety Committee (RTQAC) was formed within the radiation therapy program at the Simcoe Muskoka Regional Cancer Program, tasked with developing a framework for an incident reporting and learning system (IRLS). One year after implementation of the IRLS, the RTQAC identified that, in addition to near-miss and actual incidents, it was critical to identify and track other types of events that may indicate process inefficiency or procedure non-compliance. Tracking these events was judged paramount to identifying processes for quality improvement and to reducing the risk of an actual or near-miss incident. A simplistic user-friendly electronic reporting system was developed to track events in our processes, dubbed DeSP (Deviation from Standard Practice), to distinguish them from actual and near-misses. An audit of program processes and end-user experience was used to categorize and develop a preset menu of the most frequent events. Free-form text fields were included for types of events that were not previously identified or anticipated. The form menu is dynamic and adaptive and allows users to record more than one DeSP event per form. DeSP data is analyzed monthly for trends. Depending on the frequency and types of events, a more in-depth analysis occurs, and process quality improvement strategies are developed and implemented. Prior to the implementation of the DeSP reporting form in May 2014, the reporting of those events that are currently categorized as DeSPs in the IRLS was uncommon and averaged less than 10 per month. Since introduction of the electronic DeSP reporting form, reports have averaged 230 per month. Results from DeSP analyses have highlighted latent risks in processes that may have otherwise gone unidentified in the IRLS. The implementation of DeSP reporting has improved the sensitivity of the IRLS to measure the performance and impact of newly implemented processes. Further follow-up will evaluate whether the identification, analysis and dissemination of DeSP data can in turn reduce the frequency of DeSPs, and therefore potentially decrease the frequency of near-miss and actual incidents.