Using Incident Reports to Identify Vulnerabilities: A Case Study in Radiation Therapy

As mandatory reporting of health care incidents becomes more prevalent, the need for effective strategies for analyzing historical reports to identify vulnerabilities is increasingly important. For this project, the research team reviewed existing event narratives collected by the U.S. Nuclear Regulatory Commission (NRC) that described errors with the use of nuclear byproducts in four medical treatment modalities: gamma knife stereotactic radiosurgery, high dose rate brachytherapy, low dose rate brachytherapy, and interstitial brachytherapy. This analysis had three levels: identification of possible system vulnerabilities based on historical data, analysis of event data for trends over time and for each treatment modality, and comparison of the suggested corrective actions with the implemented corrective actions for each event. The research team identified types of errors that were more prevalent with each treatment modality, along with discrepancies between suggested corrective actions and the implemented corrective actions. This project is a case study illustrating strategies for extracting valuable information from incident-reporting databases.