IAEA E-learning Program Safety and Quality in Radiotherapy

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Sections: 4.1 Process Maps 4.2 Severity Metrics 4.3 Basic Causes 4.4 Safety Barriers In Module 3 we gained an overview of Incident Learning Systems and their key features. In this Module we’ll look in more detail at several of the key components of an ILS.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Sections: 4.1 Process Maps 4.2 Severity Metrics 4.3 Basic Causes 4.4 Safety Barriers The topic of this section is the basic or root causes.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes OBJECTIVES To understand the value of Basic Causes in an Incident Learning System. To review selected published Basic Cause Tables. The section objectives are to understand the value of basic causes in an incident learning systems, and to review selected published basic cause tables. These objectives reflect our generic approach to these four ILS topics namely process maps, severity metrics, basic causes, and safety barriers.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes OBJECTIVES To understand the value of basic causes in an incident learning system. To review selected published basic cause tables. Firstly, we will understand the value of basic causes in an incident learning system.

Safety and Quality in Radiotherapy What are Basic Causes? MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes What are basic causes? The term “basic causes” is used generically to describe those conditions which lead to or predispose a system to failure. The term “root causes” is also used. The term ‘basic causes’ is used generically to describe those conditions which lead to or predispose a system to failure. The term ‘root causes’ is also used. These terms are used interchangeably.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes What are basic causes? The term “basic causes” is used generically to describe those conditions which lead to or predispose a system to failure. The term “root causes” is also used. Unfortunately, the use of the word “cause” implies inevitability. In other words, if the cause is present, the particular failure will always occur. This is rarely the case. Unfortunately, the use of the word ‘cause’ implies inevitability. In other words, if the cause is eliminated, the particular failure that it precipitated will never occur again. This is rarely the case. This is an important point regarding the terminology employed in incident learning systems.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes What are basic causes? The term “basic causes” is used generically to describe those conditions which lead to or predispose a system to failure. The term “root causes” is also used. Unfortunately, the use of the word “cause” implies inevitability. In other words, if the cause is present, the particular failure will always occur. This is rarely the case. We will continue to use the term “basic causes” although it should be interpreted to include “contributing factors” and “latent conditions” which increase the probability of system failure but do not make failure inevitable. Some developers of incident learning systems have moved away from the terms basic and root causes. And now use the term ‘contributing factors’. We will continue to use the term basic causes although it should be interpreted to include contributing factors and latent conditions which increase the probability of system failure but do not make failure inevitable.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes What’s the purpose of basic causes? What is the purpose of basic causes? We can provide an answer within the framework of an incident learning system.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes What’s the purpose of basic causes? We need to know what precipitated the incident if we are to develop effective preventive actions. What is the purpose of basic causes? We need to know what precipitated the incident if we are to develop effective preventive actions. To make a logical connection between an incident and preventive actions to minimize the probability of such an incident happening again, we need to know what caused it or contributed to its happening.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes Free text versus a table1? Table Less ambiguity in interpretation of the causes. Easier extraction and collation of causes from a database of incidents is also easier with a defined taxonomy. The ability to collate such information contributes to a more efficient approach to error management. Free text Flexibility. The ability to elaborate on all the factors that may have precipitated the incident. Current incident learning systems include a box for a free text description of an incident. Tables are convenient for the reason that we looking at on this slide, but unlikely to cover all the possibilities. In such cases the free text option can be used to elaborate on factors that may have precipitated the incident.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes Free text versus a table1? Here is an example of the use to which a table of basic causes can be put. This is one centre’s analysis of the basic causes of clinical incidents. The basic cause taxonomy is from the Calgary system which we will see in more detail later. It is a matter of experience from several incident learning systems that have to do with standards. These practices and procedures are very frequent basic causes of incidents in the clinic. In section 1 of this module, we stressed the importance of standardized processes for safe clinic operation.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes Basic causes need to be actionable For the identification of Basic Causes to be useful they needs to lead to effective preventive Actions. For example, inadequate documentation or insufficient staff numbers are issues that, in principle, can be addressed and fixed. It is easy to identify human error as the basic cause of an incident. However, “human error” is, in general, not an actionable basic cause. In tracing the origins of an incident back to basic causes, human error likely occurred somewhere along the failure pathway. However, the value of a basic or root cause analysis is identifying the circumstances or conditions which made it more likely that a human error would be made. The situational factors that are basic causes which predispose the human being to make the error need to be identified and controlled. For example, inadequate documentation or insufficient staff numbers make errors more likely. For the identification of basic causes to be useful they need to lead to effective preventive actions. For example, inadequate documentation or insufficient staff numbers, in principle, can be addressed and fixed. This is an important point: from the basic causes we wish to develop preventive actions. It is easy to identify human error as the basic cause of an incident. Unless there's an option of automating the weak step in the process, which is frequently not the case, then the situational factors that are basic causes which predispose the human being to make the error need to be identified and controlled.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes OBJECTIVES To understand the value of basic causes in an incident learning system. To review selected published basic cause tables. Now we will review selected published basic cause tables.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes Calgary Basic Cause Table2 This is the Calgary basic cause table. This was actually adopted from one in use in the commercial chemical industry.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes SAFRON3/Calgary Basic Cause Table SAFRON adopted the Calgary table for its use.  http://www.ihe.ca/publications/library/archived/a-reference-guide-for-learning-from-incidents-in-radiation-treatment/

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes AAPM Basic Causes Table4 3. Human behavior involving staff Acting outside one’s scope of practice Slip causing physical error (failure in performance of highly developed skills as intended or maintained) Poor judgement (e.g., failure to carry out quality control on a patient due to time limitation) Language and comprehension issues Intentional rules violations (sabotage/criminal acts, criminal intent, intentional violation) Negligence (risky behavior, poor judgement in failure to address issues or extreme demands, lack of vigilance, recklessness) Here are some basic causes from the AAPM consensus document. Developing preventive actions for some of these is clearly easier than for others. And for some, such as 3.b. in the list further analysis may be necessary to take deeper into the cause of the failure. http://www.ihe.ca/publications/library/archived/a-reference-guide-for-learning-from-incidents-in-radiation-treatment/

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes summary We have: Looked at the role of Basic Causes in an Incident Learning System. Reviewed selected published Basic Cause Tables. In summary, we have looked at the roles of basic causes in an incident learning system and we have reviewed selected published basic cause tables. Basic causes are an essential component of an incident learning system as they connect the incident to the preventive actions which will help minimize the chances of a repeat. However, no basic causes table can be completely comprehensive. So basic causes and contributing factors can be elaborated in the free text option within an incident learning system.

Safety and Quality in Radiotherapy MODULE 4: process maps, severity metrics, basic causes & safety barriers Section 3: basic causes References and additional resources Clark BG, Brown RJ , Ploquin J, Dunscombe P. Patient safety improvements in radiation treatment through 5 years of incident learning. Practical Radiation Oncology 3, 157-163, 2013. Cooke DL, Dubetz M, Rahim H, et al. A reference guide for learning from incidents in radiation treatment. 2006. http://www.ihe.ca/documents/HTA-FR22.pdf. SAFRON, https://rpop.iaea.org/RPOP/RPoP/Modules/login/safron-register.htm Ford E, Fong de los Santos L, Pawlicki T , et al. Consensus recommendations for incident learning database structures in radiation oncology. Medical Physics 39, 7272-7290. 2012.