Implementation of Incident

Reporting in Radiotherapy

Karin BampsPhysicist LOC

September 3, 2010

Content

1. LOC?

2. Why Patient Safety?

3. Approach.

4. Data.

5. Conclusion/Future

1. LOC

vzw Limburgs Oncology Centre is a cooperation between Jessa Ziekenhuis, Hasselt and Ziekenhuis Oost-Limburg, Genk in radiotherapy.

1. LOC

Jessa Ziekenhuis: 3 linacsConventional SimulatorCT-Simulator (Big Bore)PET-CT-Simulator (Big Bore)Planning

Ziekenhuis Oost-Limburg:

2 linacsPlanning

1. LOC

Core mission:

The delivery of a high qualitative radiotherapy treatment in the

Limburg-region.

2. Why Patient Safety?

FANC (Federal Agency for Nuclear Control)

“It is essential, for quality assurance reasons, for each radiotherapy centre to have an internal system for recording and analyzing all incidents, in accordance with the requirements of the College of Radiotherapy and the Agency”.

(www.fanc.be)

2. Why Patient Safety?

BVRO/VVROROSIS (Radiation Oncology Safety Information System)

MAASTRO clinicsAdverse events mediaInitiatives in partner hospitals

2. Why Patient Safety?

No structured patient safety policy:

Lack of knowledge

No experience with incident reporting

No structured system for reporting

Blame and shame

3. Approach

2009

Q1 Q2 Q4Q3

Start project

Education/ Literature research

2010

Bench-marking

3. Approach

2009

Q1 Q2 Q4Q3

Start project

Education/ Literature

search

2010

Bench-marking

Start-up Patient Safety Team

3.2 Patient Safety team

Team Patient Safety

Discussion of reported incidents

Analyses and feedback

Multidisciplinary(Medical Coordinator, Radiotherapist, Nurse coordinator, 2

Nurses, Physicist, Dosimetrist and Patient Safety Coordinator)

3.3 Training

3.3.1 PRISMA Prevention and Recovery Information System for Monitoring and

Analysis

3.3.2 SAFER Scenario Analyses Fail modes Effects and Risks

3.3.3 Improvement actions

3.3.1 PRISMA

Retrospective

Directory of causesMain causes (focus on flaws in the system)Classification in human, organizational and technical causes. DatabaseAnalyses: Prisma-profileFeedback organizationAction are based on main causes

3.3.1 PRISMA

Incident Patient Safety Team(Multidisciplinary)

Improvements

Main Causes

Petra Reijnders, MAASTRO 2010

3.3.2 SAFER

Prospective (Predictive)

Identifying the ways in which a process can failEstimated riskPrioritizing the actions to reduce riskSafe implementation of new procedures

3.3.2 SAFER

Patient Safety Team(Multidisciplinary)

Design, concept

of process

SAFEROrder, severity

and changeImprovements

“What can go wrong?”

Petra Reijnders, MAASTRO 2010

3.3.3 Improvement actions

Actions to improve the system

Automation of processes

Implementation of actions(ex. Checklist, alert notes, warning

cards,…)

Monthly update with statistics and reminders

Incident reporting Team PatientSafety

PRISMA analyse

Classification main causes

Actions to improve the process

Feedback

3.2 Patient Safety team

3. Approach

2009

Q1 Q2 Q4Q3

Start project

Education/ Literature

search

2010

Bench-marking

Start-up Patient

Safety team

Internal Reporting

System

3.3 Internal reporting System

3. Approach

2009

Q1 Q2 Q4Q3

Start project

Education/ Literature

search

2010

Bench-marking

Start-up Patient Safety team

Internal Reporting System

MotivationCommunication

3.4 Motivation and communication

At the start of the incident reporting system all employees got an information session on ‘Voluntary Incident Reporting’.

What?Motivation to report (near-)missesHow to reportNo Blame

3. Approach

2009

Q1 Q2 Q4Q3

Start project

Education/ Literature

search

2010

Bench-marking

Start-up Patient Safety team

Internal Reporting System

MotivationCommunication

Analyses, classification of the main causes

Implementation of improvement

3.5 Patient Safety Commission

Report commission

Analyses of (near-)misses on the floor

Involve the reporter

Context (near-)miss

4. Data

Number of reports

28

51

2938

4338

3126

52

41

52 50

96 93

0

20

40

60

80

100

120

jun

09ju

l 09

aug

09

sep

09

okt 0

9

nov

09

dec

09

jan

10

feb

10

mrt

10

apr 1

0

mei

10

jun

10ju

l 10

4. Data

0

10

20

30

40

50

60

70

80

Jan Feb Ma Apr Mei Jun Jul

Quality issue

Near-miss

Miss

4. Data

Severity

0

2

4

6

8

10

12

14

16

18

No Small Moderate Big Severe

4. Data

Prisma-profile

HRI

HRV

HRC

T-EX

OP

HRM

HSS

OK

OM

HKK

PRF

TD

OC

H-EX

O-EX

HRQ

HST0

50

100

150

200

5. Conclusion

What did we learn?

Analyses of every reportFocus on the system, not on peopleInvolve the reporterClear feedbackPatient Safety CultureContinuous education

5. Future

Prisma-analysesNew techniques: SaferSelective treatment checkVisitationsSafety awareness trainingRCA/SIREInvolve patients

Thank you for your attention!