Reporting Gap for Near-Misses and Errors in Radiation Oncology Is Rampant

Phoebe Starr

December 2011, Vol 2, No 7 - ASTRO Annual Meeting


believe that errors and near-misses of radiation treatment should be reported, but this does not always happen, according to a study of survey results from 4 academic radiation oncology practices that was presented at the 2011 American Society for Radiation Oncology meeting.

“Although 97% of radiation oncology team members believe they have a responsibility to report near-misses and errors, up to one third reported having been involved with, or aware of, aminor event but not reporting it to voluntary in-house systems designed to capture them. This reporting gap… was seen among all members of the clinic,” said lead investigator and radiation oncology resident Kendra M. Harris,MD, Radiation Oncology, Johns Hopkins Medical Center, Baltimore.

The study comes in the aftermath of a January 23, 2010, front-page article in the New York Times on serious radiology errors, causing many radiology departments to take stock of their performance. The study was based on an anonymous survey sent to radiation staff (including attending physicians, residents, radiation therapists, nurses, dosimetrists, and physicists) at Johns HopkinsMedical Center;North Shore– Long Island Jewish Health System; Washington University School of Medicine; and theUniversity ofMiami. The response rate was 81% (N = 274).

The most prominent barrier to reporting events was a concern about professional sanctions. Other reasons given were cited by:

  • Embarrassment, 49% attending; 58% resident physicians
  • “Getting my colleagues in trouble,” 41% attending physicians, 54% resident physicians, 40% nurses, and 47% radiation therapists
  • “Admitting liability,” 33%: 41% attending physicians and 42% residents cited that as a barrier to reporting errors.

Communication failures were a common source of errors, including setup errors and those associated with complex stereotactic treatments and computer-related events. Improving communication could help to address the problem, Dr Harris said.

Dr Harris said that there are strict rules that govern the appropriate reporting of serious radiation events, but there are no mandates regarding the reporting of lesser events or nearevents and no recommendations regarding the monitoring of these events for system-based improvements.

“Even in departments with sophisticated reporting systems, all radiation oncology team members admit there is a ‘reporting gap,’” Dr Harris said. Survey respondents indicated that reporting is their responsibility, they are not too busy, and they know what to report.