{"id":"https://openalex.org/W2026446940","doi":"https://doi.org/10.1118/1.4888642","title":"SU\u2010E\u2010T\u2010310: Targeting Safety Improvements Through Analysis of Near\u2010Miss Error Detection Points in An Incident Learning Database","display_name":"SU\u2010E\u2010T\u2010310: Targeting Safety Improvements Through Analysis of Near\u2010Miss Error Detection Points in An Incident Learning Database","publication_year":2014,"publication_date":"2014-05-29","ids":{"openalex":"https://openalex.org/W2026446940","doi":"https://doi.org/10.1118/1.4888642","mag":"2026446940"},"language":"en","primary_location":{"id":"doi:10.1118/1.4888642","doi":"https://doi.org/10.1118/1.4888642","is_oa":false,"landing_page_url":"https://doi.org/10.1118/1.4888642","pdf_url":null,"source":{"id":"https://openalex.org/S95522064","display_name":"Medical Physics","issn_l":"0094-2405","issn":["0094-2405","1522-8541","2473-4209"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core","dongbi-c","doyens","jufo-1","ki-jl-1","medline","norway-1","poland-100","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320595","host_organization_name":"Wiley","host_organization_lineage":["https://openalex.org/P4310320595"],"host_organization_lineage_names":["Wiley"],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Medical Physics","raw_type":"journal-article"},"volume":null,"type":"article","is_traditional":true,"indexed_in":["crossref"],"open_access":{"is_oa":false,"oa_status":"closed","oa_url":null,"any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5030244265","display_name":"Alyssa G Novak","orcid":"https://orcid.org/0009-0003-1462-632X","observed_orcids":["https://orcid.org/0009-0003-1462-632X"]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"A Novak","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5018732676","display_name":"Matthew J. Nyflot","orcid":"https://orcid.org/0000-0002-2356-9422","observed_orcids":["https://orcid.org/0000-0002-2356-9422"]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"M Nyflot","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5025343695","display_name":"Patricia A. Sponseller","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"P Sponseller","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":null,"display_name":"J Howard","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"J Howard","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":null,"display_name":"W Logan","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"W Logan","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5074053019","display_name":"Linda Holland","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"L Holland","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5110282348","display_name":"Loucille Jordan","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"L Jordan","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5108803129","display_name":"J. Carlson","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"J Carlson","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5007161261","display_name":"Ralph P. Ermoian","orcid":"https://orcid.org/0000-0002-7514-0943","observed_orcids":["https://orcid.org/0000-0002-7514-0943"]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"R Ermoian","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5086520797","display_name":"Gabrielle M. Kane","orcid":"https://orcid.org/0000-0001-8225-6971","observed_orcids":["https://orcid.org/0000-0001-8225-6971"]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"G Kane","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5108504637","display_name":"E.C. Ford","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"E Ford","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5062492688","display_name":"Jing Zeng","orcid":"https://orcid.org/0000-0001-7388-8926","observed_orcids":["https://orcid.org/0000-0001-7388-8926"]},"institutions":[{"id":"https://openalex.org/I201448701","display_name":"University of Washington","ror":"https://ror.org/00cvxb145","country_code":"US","type":"education","lineage":["https://openalex.org/I201448701"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"J Zeng","raw_affiliation_strings":["University of Washington, Seattle, WA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"University of Washington, Seattle, WA","institution_ids":["https://openalex.org/I201448701"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":1,"corresponding_author_ids":[],"corresponding_institution_ids":["https://openalex.org/I201448701"],"apc_list":{"value":3360,"currency":"USD","value_usd":3360},"apc_paid":null,"fwci":0.0,"has_fulltext":false,"cited_by_count":1,"citation_normalized_percentile":{"value":0.17266021,"is_in_top_1_percent":false,"is_in_top_10_percent":false},"cited_by_percentile_year":{"min":88,"max":93},"biblio":{"volume":"41","issue":"6Part16","first_page":"295","last_page":"295"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9657999873161316,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9657999873161316,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T10358","display_name":"Advanced Radiotherapy Techniques","score":0.026599999517202377,"subfield":{"id":"https://openalex.org/subfields/3108","display_name":"Radiation"},"field":{"id":"https://openalex.org/fields/31","display_name":"Physics and Astronomy"},"domain":{"id":"https://openalex.org/domains/3","display_name":"Physical Sciences"}},{"id":"https://openalex.org/T11894","display_name":"Radiology practices and education","score":0.0015999999595806003,"subfield":{"id":"https://openalex.org/subfields/2741","display_name":"Radiology, Nuclear Medicine and Imaging"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/near-miss-errors","display_name":"near-miss errors","score":0.968999981880188},{"id":"https://openalex.org/keywords/radiotherapy-treatment-planning","display_name":"radiotherapy treatment planning","score":0.8650000095367432},{"id":"https://openalex.org/keywords/patient-safety","display_name":"patient safety","score":0.6169999837875366},{"id":"https://openalex.org/keywords/workflow-analysis","display_name":"workflow analysis","score":0.7950000166893005},{"id":"https://openalex.org/keywords/incident-reporting","display_name":"incident reporting","score":0.7900000214576721},{"id":"https://openalex.org/keywords/error-severity","display_name":"error severity","score":0.7350000143051147},{"id":"https://openalex.org/keywords/treatment-planning-errors","display_name":"treatment planning errors","score":0.4339999854564667},{"id":"https://openalex.org/keywords/contouring-error","display_name":"contouring error","score":0.6819999814033508},{"id":"https://openalex.org/keywords/radiation-therapists","display_name":"radiation therapists","score":0.546999990940094},{"id":"https://openalex.org/keywords/safety-checklist","display_name":"safety checklist","score":0.7789999842643738},{"id":"https://openalex.org/keywords/dosimetry","display_name":"dosimetry","score":0.7319999933242798}],"concepts":[{"id":"https://openalex.org/C177212765","wikidata":"https://www.wikidata.org/wiki/Q627335","display_name":"Workflow","level":2,"score":0.815140962600708},{"id":"https://openalex.org/C206713868","wikidata":"https://www.wikidata.org/wiki/Q1674639","display_name":"Near miss","level":2,"score":0.7688525319099426},{"id":"https://openalex.org/C2779104521","wikidata":"https://www.wikidata.org/wiki/Q23058469","display_name":"Contouring","level":2,"score":0.7376571297645569},{"id":"https://openalex.org/C41008148","wikidata":"https://www.wikidata.org/wiki/Q21198","display_name":"Computer science","level":0,"score":0.5154972672462463},{"id":"https://openalex.org/C2777363581","wikidata":"https://www.wikidata.org/wiki/Q15098235","display_name":"Harm","level":2,"score":0.5152326226234436},{"id":"https://openalex.org/C2909164965","wikidata":"https://www.wikidata.org/wiki/Q6014597","display_name":"Incident report","level":2,"score":0.4287665784358978},{"id":"https://openalex.org/C19527891","wikidata":"https://www.wikidata.org/wiki/Q1120908","display_name":"Medical physics","level":1,"score":0.41855835914611816},{"id":"https://openalex.org/C190812933","wikidata":"https://www.wikidata.org/wiki/Q28923","display_name":"Chart","level":2,"score":0.4170127213001251},{"id":"https://openalex.org/C124101348","wikidata":"https://www.wikidata.org/wiki/Q172491","display_name":"Data mining","level":1,"score":0.3503803610801697},{"id":"https://openalex.org/C77088390","wikidata":"https://www.wikidata.org/wiki/Q8513","display_name":"Database","level":1,"score":0.25263750553131104},{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.2522602677345276},{"id":"https://openalex.org/C105795698","wikidata":"https://www.wikidata.org/wiki/Q12483","display_name":"Statistics","level":1,"score":0.2221747636795044},{"id":"https://openalex.org/C200601418","wikidata":"https://www.wikidata.org/wiki/Q2193887","display_name":"Reliability engineering","level":1,"score":0.15184113383293152},{"id":"https://openalex.org/C15744967","wikidata":"https://www.wikidata.org/wiki/Q9418","display_name":"Psychology","level":0,"score":0.1442227065563202},{"id":"https://openalex.org/C38652104","wikidata":"https://www.wikidata.org/wiki/Q3510521","display_name":"Computer security","level":1,"score":0.1272388994693756},{"id":"https://openalex.org/C127413603","wikidata":"https://www.wikidata.org/wiki/Q11023","display_name":"Engineering","level":0,"score":0.11699146032333374},{"id":"https://openalex.org/C33923547","wikidata":"https://www.wikidata.org/wiki/Q395","display_name":"Mathematics","level":0,"score":0.10326215624809265},{"id":"https://openalex.org/C77805123","wikidata":"https://www.wikidata.org/wiki/Q161272","display_name":"Social psychology","level":1,"score":0.0},{"id":"https://openalex.org/C121684516","wikidata":"https://www.wikidata.org/wiki/Q7600677","display_name":"Computer graphics (images)","level":1,"score":0.0}],"mesh":[],"locations_count":1,"locations":[{"id":"doi:10.1118/1.4888642","doi":"https://doi.org/10.1118/1.4888642","is_oa":false,"landing_page_url":"https://doi.org/10.1118/1.4888642","pdf_url":null,"source":{"id":"https://openalex.org/S95522064","display_name":"Medical Physics","issn_l":"0094-2405","issn":["0094-2405","1522-8541","2473-4209"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core","dongbi-c","doyens","jufo-1","ki-jl-1","medline","norway-1","poland-100","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320595","host_organization_name":"Wiley","host_organization_lineage":["https://openalex.org/P4310320595"],"host_organization_lineage_names":["Wiley"],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Medical Physics","raw_type":"journal-article"}],"best_oa_location":null,"sustainable_development_goals":[{"display_name":"Good health and well-being","score":0.9537000060081482,"id":"https://metadata.un.org/sdg/3"}],"study_designs":[],"awards":[],"funders":[],"has_content":{"pdf":false,"grobid_xml":false},"content_urls":null,"referenced_works_count":0,"referenced_works":[],"related_works":["https://openalex.org/W2338624093","https://openalex.org/W2141932759","https://openalex.org/W2048188252","https://openalex.org/W2083932685","https://openalex.org/W2800138620","https://openalex.org/W1985557012","https://openalex.org/W1995344040","https://openalex.org/W2052971739","https://openalex.org/W1418077573","https://openalex.org/W2154444387"],"abstract_inverted_index":{"Purpose:":[0],"Radiation":[1],"treatment":[2,191,207,261],"planning":[3,251],"involves":[4],"a":[5,60,75,80],"complex":[6],"workflow":[7,97],"that":[8,231],"can":[9],"make":[10],"safety":[11,35,279],"improvement":[12,36],"efforts":[13],"challenging.":[14],"This":[15],"study":[16],"utilizes":[17],"an":[18,153],"incident":[19],"reporting":[20,64],"system":[21,65],"to":[22,31,92,100,264,290],"identify":[23],"detection":[24,104],"points":[25,105],"of":[26,106,140,187,278],"near\u2010miss":[27,81,107,141,188],"errors,":[28,108],"in":[29,149,162,249,272,281],"order":[30],"guide":[32],"our":[33,288],"departmental":[34,61],"efforts.":[37],"Previous":[38],"studies":[39],"have":[40],"examined":[41],"where":[42,47],"errors":[43,142,189,247,269],"arise,":[44],"but":[45],"not":[46],"they":[48],"are":[49,286],"detected":[50,144,157,168,173,239],"or":[51,226],"their":[52],"patterns.":[53],"Methods:":[54],"1377":[55],"incidents":[56,69],"were":[57,70,130,143,156,167,177,203,210,218,238,242],"analyzed":[58],"from":[59,66,85,175],"nearmiss":[62],"error":[63],"3/2012\u201310/2013.":[67],"All":[68],"prospectively":[71],"reviewed":[72],"weekly":[73],"by":[74,158,240,259],"multi\u2010disciplinary":[76],"team,":[77],"and":[78,103,126,165,216,237,283,293,298],"assigned":[79],"severity":[82],"score":[83],"ranging":[84],"0\u20134":[86],"reflecting":[87],"potential":[88],"harm":[89,91],"(no":[90],"critical).":[93],"A":[94],"98\u2010step":[95],"consensus":[96],"was":[98,190],"used":[99],"determine":[101],"origination":[102,176],"categorized":[109],"into":[110],"7":[111],"major":[112],"steps":[113,170],"(patient":[114],"assessment/orders,":[115],"simulation,":[116],"contouring/treatment":[117,250],"planning,":[118,208],"pre\u2010treatment":[119,223],"plan":[120,214,235],"checks,":[121,125,215],"therapist/on\u2010treatment":[122],"review,":[123],"post\u2010treatment":[124],"equipment":[127],"issues).":[128],"Categories":[129],"compared":[131],"using":[132],"ANOVA.":[133],"Results:":[134],"In":[135],"the":[136,146,150,159,163,221,273,276],"7\u2010step":[137],"workflow,":[138,151,164,274],"23%":[139,166],"within":[145],"same":[147],"step":[148,161],"while":[152],"additional":[154],"37%":[155],"next":[160],"two":[169],"downstream.":[171],"Errors":[172,230,257],"further":[174],"more":[178,243,266],"severe":[179,244,267],"(p<.001;":[180],"Figure":[181],"1).":[182],"The":[183],"most":[184],"common":[185],"source":[186],"planning/contouring,":[192],"with":[193],"476":[194],"near":[195],"misses":[196],"(35%).":[197],"Of":[198],"those":[199],"476,":[200],"only":[201],"72(15%)":[202],"found":[204,211],"before":[205],"leaving":[206],"213(45%)":[209],"at":[212,220],"physics":[213,234],"191(40%)":[217],"caught":[219,258,270],"therapist":[222],"chart":[224],"review":[225],"on":[227],"portal":[228],"imaging.":[229],"passed":[232],"through":[233],"checks":[236,280],"therapists":[241,262],"than":[245,268],"other":[246],"originating":[248],"(1.81":[252],"vs":[253],"1.33,":[254],"p<0.001).":[255],"Conclusion:":[256],"radiation":[260],"tend":[263],"be":[265],"earlier":[271],"highlighting":[275],"importance":[277],"dosimetry":[282,297],"physics.":[284,299],"We":[285],"utilizing":[287],"findings":[289],"improve":[291],"manual":[292],"automated":[294],"checklists":[295],"for":[296]},"counts_by_year":[{"year":2021,"cited_by_count":1}],"updated_date":"2026-10-30T12:39:25.321706","created_date":"2016-06-24T00:00:00"}