Incident Learning in a Radiation Oncology Practice During the COVID Era

PURPOSE/OBJECTIVE(S): Incident learning is key to developing and maintaining quality and safety in healthcare. This work aims to quantify how submissions to our incident learning system and contributing factors for events have changed in the time of COVID. MATERIALS/METHODS: Events from our incident learning system were analyzed for the 11 months pre-COVID (March 1, 2019 - January 31, 2020) and compared to 11 months during COVID (March 1, 2020 - January 31, 2021). Descriptive statistics were used to evaluate and compare the reporting rate, incident severity, contributing factors, and where in patient pathway the incident originated and was caught. RESULTS: See Table. CONCLUSION: During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. This is perhaps related to a decline in the number of treatments delivered during COVID and the presence of new COVID-related workflows. The site of origin of the incidents was similar pre- vs. during-COVID. However, the locations where incidents were caught (detected) shifted to more near-'end of the line' safeguards (e.g., pre-RT Physics and RTT chart checks & write-up), suggesting a potential degradation of safeguards present earlier in the process (e.g., pre-RT peer review, Dosimetry pre-RT check). Communication, hand-offs, and cross-coverage were more likely to be contributing factors during COVID which is most likely attributable to people working virtually/remotely during the pandemic. This emphasizes the need to reduce inter-provider variations, and consistent standards for communication and treatment.