AHRQ Patient Safety Network ► Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.

AHRQ Patient Safety Network





Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.

Gabriel PE, Volz E, Bergendahl HW, et al. Jt Comm J Qual Patient Saf. 2015;41:160-168.

This study describes the experience of an incident learning program in a radiation oncology department over a nearly 4-year period. Approximately 78% of all staff had reported at least one incident, representing a high level of frontline engagement. The department also saw significant improvements in AHRQ Patient Safety Culture scores following implementation of the program.

Available at 

Related Resources

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

STUDY

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

STUDY

Factors associated with reported preventable adverse drug events: a retrospective, case-control study.

Beckett RD, Sheehan AH, Reddan JG. Ann Pharmacother. 2012;46:634-641.

BOOK/REPORT

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.

View all related resources...