Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy: The Primary Experience in a New Established Program with Advanced Technology
Table 6
Summary of causes/contributory factors for reported incidents (in parentheses) and near misses.
Category
First year
Second year
Total
1biv
policy not followed
7 (5)
3
10 (5)
1cii
Appropriate skills not acquired from vendor provided training
2 (1)
1
3 (1)
1ciii
inadequate periodic assessment of staff competencies
3
1
4
1civ
lack of continuing education
3
1
4
1div
Communication
2
1
3
2bii
equipment design and construction issues
1
0
1
2biv
networking problems
(1)
0
(1)
3f,
Negligence
12 (3)
4
16 (3)
6aiii
failure to detect a developing problem
1
0
1
6div
failure to develop an effective plan
1
4
5
6eii
failure to execute the planned action
(1)
0
(1)
7
Other
0
2
2
Total
32 (11)
17
49 (11)
Comments: The data indicate the number of causes/contributory factors, not the number of near misses/incidents.
