Deviation from Standard Practice Reporting – a Novel Technique to Directly Improve Quality and Safety within Radiation Treatment Program

Radiation treatment (RT) is a complex, multidisciplinary enterprise, consisting of many exchanges of tasks amongst various professionals. As a result, each step of a patient's RT journey contains inherent hazards. Incident reporting and learning are essential components of any organization. The focus, however, is often on near-miss and adverse events. Many events occurring in the preparation of a patient’s RT do not fall into any of these categories. Some could just be random occurrences, but some could be symptoms of something deeper which on the surface seem to be inconsequential. Not only do these types of events often result in process inefficiencies, they could contribute to an adverse event if left propagated throughout the system. We aim to track and act on these events, named Deviation from Standard Practice (DeSP), in order to improve RT processes and thereby pre-emptively mitigate a near-miss or an adverse event. We presented the DeSP reporting and learning framework concept at the RTi3 conference four years ago. In this presentation, we aim to provide an update and show some of the impacts of DeSP reporting. At its implementation, we developed an electronic form with a simple, user-friendly design, to facilitate its use and minimize disruption of clinical flow. The form is frequently updated, based on input from staff as well as accounting for emerging events and newly implemented processes. DeSP reports are disseminated to staff bi-weekly. Depending on the frequency and type of a DeSP event, a more in-depth analysis may incur, and quality improvement strategies are developed. The impact of these interventions are then monitored and evaluated regularly. Process changes are communicated in a timely manner to affected team. Prior to its implementation, the reporting of those events that are currently categorized as DeSPs was uncommon and averaged less than 10 per month. In the first year of introducing DeSP reporting, we averaged 230 DeSP events per month, reflecting the need for this type of reporting. Staff engagement continues to be strong, four years later, with reports averaged to 140 per month. Many RT processes have been modified and improved based on the DeSP data collected. The same DeSP form may be used to monitor the impact of an intervention made to a process. Information provided by DeSP reports also have far reaching implications, such as improving interdisciplinary communication. Challenges include changing staff view of incident reporting as punitive, be it a near-miss, an adverse event or a DeSP. Over the years we have found that DeSP offers new insight into an organization’s front-line operations, and is continually seeding quality improvement plans. We continuously modify and improve the operation of the DeSP reporting and analyzing methodology. In order to ensure its sustainability, our team is currently undergoing a review of all of the DeSP reports, in order to come up with a Minimum Data Set (MDS). This MDS will contain the categories that are encompassing all actionable and controllable events (e.g., no random one-off error), and robust against minor program changes.