Journey toward high reliability: A comprehensive safety program to improve quality of care and safety culture in a large, multisite radiation oncology department

Kristina Demas Woodhouse, Edna Volz, Amit Maity, Peter E. Gabriel, Timothy D. Solberg, Howard W. Bergendahl, Stephen M. Hahn

Research output: Contribution to journalArticle

4 Scopus citations


Background High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. Methods In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. Results Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P

Original languageEnglish (US)
Pages (from-to)e603-e612
JournalJournal of Oncology Practice
Issue number5
StatePublished - May 1 2016


ASJC Scopus subject areas

  • Oncology
  • Oncology(nursing)
  • Health Policy

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