Staff Error

Abstract: Background Radiation oncology (RO) is a high-risk environment with an increased potential for error due to the complex automated and manual interactions between heterogeneous teams and advanced technologies. Errors involving procedural deviations­­ can adversely impact patient morbidity and mortality. Under-reporting of errors is common in healthcare for reasons such as fear of retribution, liability, embarrassment, etc. Incident reporting is a proven tool for learning from errors and, when effectively implemented, can improve quality and safety. Crew resource management (CRM) employs just culture principles with a team-based safety system. The pillars of CRM include mandatory error reporting and structured training to proactively identify, learn from, and mitigate incidents. High-reliability organizations, such as commercial aviation, have achieved exemplary safety performance since adopting CRM strategies. Objective Our aim was to double the rate of staff error reporting from baseline rates utilizing CRM strategies during a six-month study period in a hospital-based radiation oncology (RO) department. Methods This quasi-experimental study involved a retrospective review of reported radiation oncology incidents between January 2015 and March 2016, which helped inform the development and implementation of a two-step custom CRM training and incident learning system (ILS) intervention in May 2016. A convenience sample of approximately 50 RO staff (Staff) performing over 100 external beam and daily brachytherapy treatments participated in weekly training for six months while continuing to report errors on a hospital-enterprise system. A discipline-specific incident learning system (ILS) customized for the department was added during the last three months of the study, enabling staff to identify, characterize, and report incidents and potential errors. Weekly process control charts used to trend incident reporting rates (total number of reported incidents in a given month /1000 fractions), and custom reports characterizing the potential severity as well as the location of incidents along the treatment path, were reviewed, analyzed, and addressed by an RO multidisciplinary project committee established for this study. Results A five-fold increase in the monthly reported number of incidents (n = 9.3) was observed during the six-month intervention period as compared to the 16-month pre-intervention period (n = 1.8). A significant increase (>3 sigma) was observed when the custom reporting system was added during the last three study months. Conclusion A discipline-specific electronic ILS enabling the characterization of individual RO incidents combined with routine CRM training is an effective method for increasing staff incident reporting and engagement, leading to a more systematic, team-based mitigation process. These combined strategies allowed for real-time reporting, analysis, and learning that can be used to enhance patient safety, improve teamwork, streamline communication, and advance a culture of safety.

Abstract: Human error and surgical site infections (SSIs) pose a considerable threat to the surgical patient. Much research has been directed at decreasing the incidence of both staff error and SSIs within the operating theatre to reduce patient morbidity and mortality. This article examines the techniques recommended for the creation of a safe operating environment, and the evidence behind the strategies for reducing the risk of SSI by thorough patient preparation, the use of good sterile technique and surgical site preparation.

Abstract: By introducing the particular variable-staff error learning, this essay discusses the relationship between goal orientation in performance appraisal and staff innovative behavior. The results show that: the development-oriented performance appraisal can positively affect the staff innovative behavior, while evaluation-oriented performance appraisal plays a negative role, and the above said relationship is reflected in the mediation of staff error learning.