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Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.
To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program.
Broad implementation of incident reporting is one of the targets of health policy in many countries including the Netherlands.
This section also contains a "focal theme" (i.e. the implementation of incident reporting systems because they are currently one of the most widely used CRM tools [ 2]) that may be changed in future applications of the instrument depending on developments in the field and trends in CRM.
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In some countries, the implementation of incident-reporting systems is accompanied by regulations that oblige the hospital management to create an atmosphere in which physicians do not have to fear that incident reporting will lead to punitive measures.
The purpose of this work is to explore the implementation and effectiveness of incident learning using a system developed based on AAPM recommended database structure in a new established program of radiation oncology with advanced technology.
Our results show that implementation of an effective incident learning system may serve to reduce the occurrence of actual incidents, enhance the culture of safety, and encourage the reporting of potential incidents as a proactive means of enhancing safety and quality in a radiation treatment program.
Two phases—(1) development and implementation of the CIRIS incident reporting safety registry and (2) development of the handheld-computer interface were implemented.
The development and implementation of the fall incident reporting system is described in detail elsewhere [ 15].
Coupled with implementation of better exposure incident information systems [ 46], they should facilitate more explicit evaluations of the impacts of environmental policies and programs.
Questionnaires were delivered at baseline and at follow-up 6 months after implementation, and the proportion of incident reports at the two hospitals was measured during a 1-year period prior to and after implementation (figure 1).
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