Main Session
Sep
28
PQA 03 - Digital Health Innovation and Informatics, Patient Safety & Quality, and Radiation and Cancer Biology
2409 - Standardizing Incident Learning Follow-Up and Escalation across a Multi-Site Academic Radiation Oncology
Presenter(s)
Roberta Anderson, OCN, RN, DNP - Johns Hopkins University, Baltimore, MD
R. Anderson1, S. Han-Oh2, J. Yu3, E. Huang1, L. Bell2, P. Thomas1, and A. N. Halthore3,4; 1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD, 2The Johns Hopkins Hospital, Baltimore, MD, 3Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Washington, DC, 4Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
Purpose/Objective(s):
Variability in follow-up processes within incident learning systems may limit timeliness, accountability, and system-level learning. We hypothesized that development of a standardized, risk-based Standard Operating Procedure (SOP) for Radiation Oncology Incident Learning System (RO-ILS) follow-up would improve process reliability, structured escalation, and cross-site learning within a multi-site academic radiation oncology program while reinforcing a just, non-punitive safety culture.Materials/Methods:
An interdisciplinary leadership team developed a department-wide SOP governing RO-ILS event review, follow-up, documentation, and escalation across sites and disciplines. The SOP defines roles, timelines, and accountability metrics. All submissions undergo initial review within 24 hours and are risk-stratified as high, moderate, or low, with target documentation completion within 7, 14, or 30 days, respectively. Complex events requiring multidisciplinary or regulatory input permit extended timelines with interim documentation. Recurrent patterns trigger escalation to multidisciplinary workflow review, assignment of action owners, and structured monitoring through Safety and Quality and Comprehensive Unit-based Safety Program structures. Educational dissemination uses de-identified, system-focused learning to avoid individual attribution.Results:
The SOP establishes a standardized framework for risk-based follow-up and escalation across multiple practice sites. Defined timelines and structured escalation pathways are designed to improve documentation consistency, visibility of recurrent system vulnerabilities, and multidisciplinary engagement in mitigation planning. Process metrics, including timeliness of review and completion rates, will be evaluated following phased implementation.Conclusion:
Development of a standardized SOP for RO-ILS follow-up provides a scalable framework to strengthen radiation oncology safety infrastructure. This model promotes accountability, system-level learning, and regulatory readiness, and may serve as a template for other multi-site programs seeking to operationalize just culture principles within incident learning systems. AI-assisted tools were used for language refinement. The authors take full responsibility for the content.