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