Limitations in learning: How treatment verifications fail and what to do about it?

PURPOSE: The purposes of this study were: to provide dialog on why classic incident learning systems have been insufficient for patient safety improvements, discuss failures in treatment verification, and to provide context to the reasons and lessons that can be learned from these failures.

METHODS AND MATERIALS: Historically, incident learning in brachytherapy is performed via database mining which might include reading of event reports and incidents followed by incorporating verification procedures to prevent similar incidents. A description of both classic event reporting databases and current incident learning and reporting systems is given. Real examples of treatment failures based on firsthand knowledge are presented to evaluate the effectiveness of verification. These failures will be described and analyzed by outlining potential pitfalls and problems based on firsthand knowledge.

RESULTS: Databases and incident learning systems can be limited in value and fail to provide enough detail for physicists seeking process improvement. Four examples of treatment verification failures experienced firsthand by experienced brachytherapy physicists are described. These include both underverification and oververification of various treatment processes.

CONCLUSIONS: Database mining is an insufficient method to affect substantial improvements in the practice of brachytherapy. New incident learning systems are still immature and being tested. Instead, a new method of shared learning and implementation of changes must be created.