This chapter discusses the nature of error, the classification of error, concepts in quality management, types of error mitigation, hierarchy of interventions, and the role of culture in error prevention. Psychologists have proposed a dual system processing theory for thought. More recently, a classification system based on Reason’s error categorization, Human Factors Analysis and Classification System (HFACS), has been demonstrated to improve standardization of error classification, increase the specificity of error classification, and facilitate the development of actionable corrective plans. Readers are directed to the guidance from the American Society for Radiation Oncology (ASTRO) on this subject for a detailed treatise on the components of peer review. An effective quality management program depends on a robust understanding of error, appropriate classification of error, the application of a systems approach to problem solving, the careful choice and implementation of error mitigation strategies, and a commitment to continuous improvement.
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This chapter explores the impact of all manner of radiotherapy incidents, and comments on the role of reporting, methods of investigation, and the path to meaningful improvement. The impact of harmful incidents on patients is sometimes immediate and life changing. Although the physical impact of incidents on patients can be direct, immediate, and known for certain incidents, they are more commonly unknown. The psychological impact of known incidents on patients is typically profound. The airline and nuclear power industries study their incidents using a root cause analysis (RCA) technique, developed for investigating industrial accidents. An investigation of an incident is a bit like detective work, where evidence is reviewed to piece together what happens. After completing an incident investigation, the practice should consider implementing improvements. Effective implementation of incident investigation, monitoring for effectiveness, and support for staff involved in error can result in the development of a true learning organization.