Implementation of Incident Reporting in Radiotherapy Karin Bamps Physicist 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 linacs Conventional Simulator CT-Simulator (Big Bore) PET-CT-Simulator (Big Bore) Planning Ziekenhuis Oost-Limburg : 2 linacs Planning

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”. (

2. Why Patient Safety? BVRO/VVRO ROSIS (Radiation Oncology Safety Information System) MAASTRO clinics Adverse events media Initiatives 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 Q1Q2Q4Q3 Start project Education/ Literature research 2010 Bench- marking

3. Approach 2009 Q1Q2Q4Q3 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 PRISMA Prevention and Recovery Information System for Monitoring and Analysis SAFER Scenario Analyses Fail modes Effects and Risks Improvement actions

3.3.1 PRISMA  Retrospective Directory of causes Main causes (focus on flaws in the system) Classification in human, organizational and technical causes. Database Analyses: Prisma-profile Feedback organization Action 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 fail Estimated risk Prioritizing the actions to reduce risk Safe implementation of new procedures

3.3.2 SAFER Patient Safety Team (Multidisciplinary) Design, concept of process SAFER Order, severity and change Improvements “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 Patient Safety PRISMA analyse Classification main causes Actions to improve the process Feedback 3.2 Patient Safety team

3. Approach 2009 Q1Q2Q4Q3 Start project Education/ Literature search 2010 Bench- marking Start-up Patient Safety team Internal Reporting System

3.3 Internal reporting System

3. Approach 2009 Q1Q2Q4Q3 Start project Education/ Literature search 2010 Bench- marking Start-up Patient Safety team Internal Reporting System Motivation Communication

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-)misses How to report No Blame

3. Approach 2009 Q1Q2Q4Q3 Start project Education/ Literature search 2010 Bench- marking Start-up Patient Safety team Internal Reporting System Motivation Communication 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

Prisma-profile

5. Conclusion What did we learn? Analyses of every report Focus on the system, not on people Involve the reporter Clear feedback Patient Safety Culture Continuous education

5. Future Prisma-analyses New techniques: Safer Selective treatment check Visitations Safety awareness training RCA/SIRE Involve patients

Thank you for your attention!