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Proceedings of the fourth Resilience Engineering Symposium

Erik Hollnagel
Éric Rigaud
Denis Besnard

Bridging Professional Silos In Radiation Medicine: The Ottawa Hospital Experience

Jodi Ploquin, Robert J. Brown et Brenda Clark


This paper presents the Incident Learning System, our 4-year data, and the resulting improvements that have been made to safety and quality of the Radiation Medicine Program of the Ottawa Hospital Cancer Centre. This paper also discusses the composition and functioning of the Radiation Oncology Quality Improvement Committee (ROQIC) at the Ottawa Hospital, highlighting how we have overcome professional silo-ing which is often a barrier to safety in healthcare. Without addressing and overcoming this problem, our program would not have achieved the significant improvements in quality and safety that we have seen over the past four years.

Note de l’auteur

Note portant sur l’auteur1

Note portant sur l’auteur2

Note portant sur l’auteur3

Texte intégral

1 Introduction

1It is estimated that one in four individuals will face cancer in their lifetime, and approximately half will have radiation as part of their treatment regime. The goal of radiotherapy is to deliver the prescribed dose to the prescribed volume, whilst minimizing the damage to normal tissue.

2Each year the Ottawa Hospital Cancer Centre Radiation Medicine Program sees approximately 4, 000 new patients per year, and delivers approximately 70,000 external beam treatments. The multidisciplinary team who work together to design and deliver these treatments as prescribed is comprised of 95 radiation therapists, 18 radiation oncologists, 15 medical physicists, and 15 technical staff. The technology used consists of 12 external beam accelerators (6 – 18 MV photons), 1 orthovoltage unit (100 – 300 kV photons), and 1 high dose rate brachytherapy unit (10 Curie Iridium-192 source).

3The World Health Organization has described the process of radiotherapy in the following sequential steps shown in Figure 1. Between these steps there is a transfer of data and many hand-offs between individuals.

4Incidents in radiotherapy have come into the spotlight/received considerable media attention over the last few years. For example, the Lisa Norris Case in Glasgow (2006), the Epinal incident in France (2008), and the 2010 New York Times series featuring front page articles such as: “The Radiation Boom: Radiation Offers New Cures and Ways to Do Harm” telling the story of patients who were severely handicapped or were dead as the result of radiation therapy “accidents” [Bogdanich, 2010]. Our own institute suffered a critical incident in 2007, when a calibration error on our orthovoltage treatment unit was discovered that resulted in over 300 patients having been under-dosed [Dunscombe, Lau & Silverthorne, 2008].

Figure 1: Sequential steps in the delivery of radiotherapy [adapted from World Health Organization Radiotherapy Risk Profile, 2008]

5This attention led the American Association of Physicists in Medicine (AAPM) and the American Society of Radiation Oncology (ASTRO) to cosponsor a meeting “Safety in Radiation Therapy: A Call to Action” in June 2010, and other professional & safety organizations including the International Commission on Radiological Protection, the World Health Organization, and the British Institute of Radiology in collaboration with the National Safety Patient Agency) to publish guidance on the safe delivery of radiation therapy [Hendee & Herman, 2011], [International Commission on Radiological Protection, 2009], [World Health Organization, 2008]. Each effort has yielded a set of recommendations, all of which include the need to have a multidisciplinary team to investigate and analyze incidents to learn from them, and a formal incident reporting system. Several sets of recommendations highlight specifically the need for professional groups within the Radiotherapy process to work together cohesively.

2 Methods

6The Ottawa Hospital has had such a group since 2007 and have made great strides in bridging the professional silos that exist within distinct professions in radiation medicine; radiation therapists, radiation oncologists, and medical physicists through a shared focus to improve the safety and quality of radiotherapy delivered by our team.

7In 2007 the Radiation Oncology Quality Improvement Committee implemented the Incident Learning System (ILS) developed at the Tom Baker Cancer Centre in Calgary, AB, Canada [Cooke, Dubetz, Heshmati & al, 2006]. In this System, an incident is defined as “an unwanted or unexpected change from a normal system behavior that causes or has the potential to cause an adverse effect to persons or equipment”. Staff report the incident using a paper form and submits to their manager. The manager enters the incident into the ILS spreadsheet. Each incident is delegated to the appropriate ROQIC member who then leads the investigation, causal analysis and follow up. Every incident is discussed at the weekly meeting of the Radiation Oncology Quality Improvement Committee, where incidents are then considered from a multi-disciplinary perspective.

8The challenge of engaging physicians in reporting culture is a well-known cultural barrier in healthcare. “In consequence establishing a ‘‘reporting culture’’ or even a ‘‘safety culture’’ requires more than removing blame or establishing reporting processes, but requires engaging with the complex culture of medicine. This could include stimulating medical ownership or control in the processes of reporting and enhancing awareness about the function of reporting.” [Waring, 2005, p.1934].

9By having every member, including a radiation oncologist, active in incident investigation, causal analysis and follow up for their area, every member is invested in the Incident Learning System. Each committee member understands the culture within their particular silo and how to best communicate and facilitate change within that ‘silo’. Change designed and brought forward by “one of their own” is better accepted within each professional silo.

10A subcommittee, customized to the incident, is formed for incidents of higher severity and reoccurring incidents to perform a more in-depth analysis of the incident. Incidents of high educational value are tagged and are included as case studies reviewed with the Radiation Medicine Program when quarterly ILS statistics are presented. The quarterly statistics and case studies reviewed keep the reporting culture strong, as they demonstrate to staff that their reporting leads to positive change. Representatives from every professional silo (radiation oncology, radiation therapy, medical physics, and radiation safety) have presented the work of our committee at the meetings of their respective professional organizations indicating ownership and pride in the successes we achieved.

3 Results

11We have developed an open and ‘just’ reporting culture with at least 400 incidents (actual and potential) reported per year, with all professional ‘silos’ engaged in incident reporting.

12From our ILS data we have learned what machines and processes are error-prone, and have learned of shortcomings in the policies and procedures, allowing us to make management decisions and changes to reduce the likelihood of errors. [Clark, Brown, Ploquin & al., 2010]. The changes implemented have led to a significant reduction in serious actual incidents (95% reduction) and major actual incidents (75% reduction) since implementation in 2007. A summary of the gains seen each year are given in Table 1. A closer look at the breakdown of just the clinical actual incidents is given in Table 2.

Table 1: Overview of ILS data

Table 1: Overview of ILS data

Note *: number of incidents/number of treatment fractions

Table 2: Nature of actual clinical incidents

Table 2: Nature of actual clinical incidents

4 Discussion & Future Work

13Without addressing and overcoming the cultural barriers that exist between the professional silos involved in Radiation Medicine, our program would not have achieved the significant improvements in quality and safety that we have seen over the past four years.

14That being said, we have come to recognize that the Incident Learning System in use is considered a classic (linear) model, and therefore has limitations to the success that can be achieved the complex, dynamic system of radiation therapy.

15In terms of the evolution of the reporting and safety culture we have developed, in 2007 we adopted the Incident Learning System developed by the Tom Baker Cancer Centre, with some modifications [Cooke, Dubetz, Heshmati & al., 2006] In 2009 we added the National Patient Safety Agency’s basic hierarchy list to our reference manual, with a focus on being conscious of the relative effectiveness of interventions when choosing corrective actions. We also added process and criteria for incidents requiring more in-depth analysis. In 2010 our focus shifted on other initiatives to improve quality and safety such as human factors analyses of radiation therapy, reviewing work published on the subject and applying it to our program [Chan, Islam, Rosewall & al., 2010], [Portaluri, 2009], [Rivera, Karsh, 2008]. Attendance at the Spring Symposium of the Canadian Chapter of the Safety Systems Society in June 10, 2010 inspired our group to explore the concept of system resilience, defined by Wreathall as“the ability of an organization (system) to maintain, or recover quickly to, a stable state, allowing it to continue operations during and after a major mishap or in the presence of continuous stress” [Wreathall, 2006, p.275]. Indeed, the stresses and challenges of modern radiation therapy are considerable, and well summarized by recent publications [Marks, Jackson, & Xie, 2011], [Herman & Hendee, 2011]. In particular, many of the recent radiation therapy

16accidents are attributed to the rapid and frequent introduction of new technology and complex techniques in radiation therapy. As highlighted by the research of Karen Cardiff, classical (linear) safety models used in health care “have largely ignored issues related to what it means to create safety in complex, dynamic settings, such as preparing frontline staff to cope with the complexity that they face on a daily basis and supporting them to become more experienced with anticipating what might go wrong (requisite imagination) and knowing when and how to adapt their performance under conditions of uncertainty.” [Cardiff, 2010].

17We have since been participating in Resilience Learning Network Teleconference & collaboratiing with researchers Cardiff & Sheps at the University of British Columbia, whose work is focused on resilience engineering in healthcare. We are hope to begin using resilience engineering tools in August 2010 to further improve the safety of Radiation Medicine at the Ottawa Hospital Cancer Centre [Sheps & Cardiff, 2011].

5 Conclusion

18We have established a team of ‘safety champions’ working together from all professional silos of the Radiation Medicine Program. Through application of the Incident Learning System since 2007, we have seen significant quality and safety improvements. Having overcome the cultural barriers that impair safety culture in healthcare, our group is able to work together to apply emerging safety theories in the pursuit of having Radiation Medicine achieve the status of being a highly reliable, resilient system.



Bogdanich, W. (2010). The radiation boom -radiation offers new cures and ways to do harm. New York ed. The New York Times (Jan. 23, Sect. A1):

British Institute Radiology, Institute of Physics and Engineering and Medicine, National Patient Safety Agency, Society and College of Radiographers and Radiologists TRCo. Towards Safety Radiotherapy (2008). Ref No: BFCO(08)1 2008.

Cardiff, K. (2010). If you think quality and safety are the same thing…think again. Presented at the Safety Systems Society Canadian Chapter Spring Symposium; Ottawa; Ontario; June 10, 2010:

Chan, A. J., Islam M.K., Rosewall T. & al. (2010). The use of human factors methods to identify and mitigate safety issues in radiation therapy. Radiother & Oncol, 97, 596-600.

Clark, B. R., Brown R. J., Ploquin J. & al. (2010). The management of radiation treatment error through incident learning. Radiother & Oncol, 95, 344-349.

Cooke, D.L., Dubetz, M., Heshmati, R. & al. (2006). A Reference Guide for Learning from

Incidents in Radiation Treatment. Calgary, AB:

Dunscombe P, Lau H, Silverthorne S. (2008). The Ottawa Orthovoltage Incident: report of the Panel of Experts convened by Cancer Care Ontario:

Hendee, W. R., Herman, M. G. (2011). Improving patient safety in radiation oncology. Med Phys, 38(1), 78-82.

International Commission on Radiological Protection. (2009). Publication 112, Preventing accidental exposures from new external beam radiation therapy technologies.

Marks, L.B., Jackson, M., Xie, L. (2011). The challenges of maximizing safety in radiation oncology. Practical Radiation Oncology, 1, 2 – 14.

Portaluri, M. (2009). Incidents analysis in radiation therapy: application of the human factors analysis and classification system. Ann Inst Super Sanita, 45(2), 128 – 133.

Rivera, A.J., Karsh, B. (2008). Human factors and systems engineering approach to patient safety for radiotherapy. Int J Radiat Oncol Biol Phys, 71(1), S174-177.

Sheps, S.B., Cardiff, K. (2011). Resilience engineering: A necessary shift in thinking and practice to improve the management of patient safety. A synthesis report submitted to the Canadian Health Services Research Foundation.

Waring, J. (2005). Beyond blame: cultural barriers to medical incident reporting. Social Science & Medicine, 60, 1927-1935.

World Health Organization. (2008). Radiotherapy risk profile: technical manual. Geneva, Switzerland: WHO publishing:


1 Radiation Safety & Health Physics, The Ottawa Hospital, Ottawa, ON, Canada

2 The Radiation Medicine Program, The Ottawa Hospital, Ottawa, ON, Canada,

3 The Radiation Medicine Program, The Ottawa Hospital, Ottawa, ON, Canada, brclark@toh.onca

Table des illustrations

Légende Figure 1: Sequential steps in the delivery of radiotherapy [adapted from World Health Organization Radiotherapy Risk Profile, 2008]
Fichier image/jpeg, 76k
Titre Table 1: Overview of ILS data
Légende Note *: number of incidents/number of treatment fractions
Fichier image/jpeg, 92k
Titre Table 2: Nature of actual clinical incidents
Fichier image/jpeg, 232k

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