National Incident Learning
Todd PawlickiUC San DiegoDept of Radiation Medicine & Applied Sciences
ASTRO/AAPM Incident Learning System (RO•ILS)
Safety Triangle
Fatality
Severe Injury
Minor Injury
Near Miss
Bad Practices
Majority of incidents
are here.
“Free Lessons”
Successful Incident Learning
• Reporting system and guidelines• Share data and provide feedback
• Part of quality/safety improvement program• Explicit support from leadership
• Appropriate organizational culture• Safety, Reporting, Just
• Competence to interpret reported data • Ability to make process changes
3
A Radiotherapy Example
Med Phys 2010
Approximately 0.6 events per treated patient
Opportunities
• Quality and safety improvement• Positive employee experience
• Education – “I did not know that!”• Better insight into processes
• Resource and effort allocation • Whether or not quality/safety interventions work
ASTRO/AAPM
• Each department should have a department-wide review committee…
• Employees should be encouraged to report both errors and near-misses
Zietman et al. 2012
PSQIA
• Patient Safety and Quality Improvement Act• Signed into law July 29, 2005• Share information about patient safety events without
liability• Allowed for the creation of Patient Safety
Organizations (PSOs)
What is a PSO?
• An entity listed by AHRQ• Operationalize PSIQA for healthcare organizations
www.claritygrp.com
ASTRO/AAPM ILS Improvement
PSQIA
Intervention
Analysis (ROHAC)
Incident or near-miss
report
Protected Space
Anna Marie HajekPresident & CEOClarity Group, Inc.
The ASTRO/AAPM System
Provider Database
Analysis and
Reports
Send to
PSODatabase
Analytics and Analysis by RO-HAC
Provider’s PSES Clarity PSO PSES
National Safety Alerts and Reports
PSO: Patient Safety OrganizationPSWP: Patient Safety Work ProductPSES: Patient Safety Evaluation SystemPSWP
RO•ILS
RO•ILS
RO•ILS
RO•ILS
Follow-up
• Identify contributing factors
• Add additional information
• Record corrective actions
Status of the RO•ILS
• Currently in beta testing
• Official release Q1/Q2 2014• Free to ASTRO members
• Must have contract with Clarity PSO
What to Report?
• Major events
• Minor frequent events
• Near-misses
• Unsafe/unexpected conditions
May Still Need Other Reporting
• Must follow all Federal and State reporting requirements• NRC
• California
• CA Department of Public Health (CDPH)• Radiologic Health Branch
State of California
• CT or RT dose that results in unanticipated permanent functional damage• To organs or system, hair loss, erythema, etc.
• Wrong individual, wrong site• Total dose delivered differs from RX by > 20%• Other criteria mostly following NRC
requirements
• Initial report within 5 days of discovery
Info Provided to CDPH
• Person making report, job title, contact info• Date(s) of event• Facility• Radiation generating equipment info (make, model, etc)• Operator’s name• Attending MD’s name and contact info• Copy of MD’s order for procedure• Reason for reporting event• Copies of internal investigation report(s) w/ dose calc• Copies of letters sent to patient, referring MD, etc
Send Information To:
CDPH RHB
Chief, X-Ray ICE
Event Notification
Radiologic Health Branch
California Department of Public Health
P.O. Box 997414, MS 7610
Sacramento, CA 95899-7414
via snail-mail letter
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