Durable Improvement in Patient Safety Culture Over 5 Years With Use of High-volume Incident Learning System

Pehr E. Hartvigson, Aaron S. Kusano, Matthew J. Nyflot, Loucille Jordan, Tru Khang Dinh, Patricia A. Sponseller, Ashlee Schindler, Gabrielle M. Kane, Eric C. Ford

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Purpose: Incident learning systems (ILSs) require substantial time and effort to maintain, risking staff burnout and ILS disuse. Herein, we assess the durability of ILS-associated safety culture improvements and ILS engagement at 5 years. Methods and materials: A validated survey assessing safety culture was administered to all staff of an academic radiation oncology department before starting ILS and annually thereafter for 5 years. The survey consists of 70 questions assessing key cultural domains, overall patient safety grade, and barriers to incident reporting. A χ2 test was used to compare baseline scores before starting the ILS (pre-ILS) with the aggregate 5 years during which ILS was in use (with ILS). ILS engagement was measured by the self-reported number of ILS entries submitted in the previous 12 months. Results: The survey response rate was ≥68% each year (range, 68%-80%). High-volume event reporting was sustained (4673 reports; average of 0.9 ILS entries per treatment course). ILS engagement increased, with 43% of respondents submitting reports during the 12 months pre-ILS compared with 64% with ILS in use (P < .001). Significant improvements (pre- vs. with-ILS) were observed in the cultural domains of patient safety perceptions (25% vs 39%; P < .03), and responsibility and self-efficacy (43% vs 60%; P < .01). The overall patient safety grade of very good or excellent significantly increased (69% vs 85%; P < .01). Significant reductions were seen in the following barriers to error reporting: embarrassment in front of colleagues, getting colleagues into trouble, and effect on department reputation. Conclusions: Comprehensive incident learning was sustained over 5 years and is associated with significant durable improvements in metrics of patient safety culture.

Original languageEnglish (US)
Pages (from-to)e407-e416
JournalPractical Radiation Oncology
Issue number4
StatePublished - Jul 1 2019

ASJC Scopus subject areas

  • Oncology
  • Radiology Nuclear Medicine and imaging


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