implementation of incident reporting in radiotherapy karin bamps physicist loc september 3, 2010
TRANSCRIPT
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Implementation of Incident
Reporting in Radiotherapy
Karin BampsPhysicist LOC
September 3, 2010
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Content
1. LOC?
2. Why Patient Safety?
3. Approach.
4. Data.
5. Conclusion/Future
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1. LOC
vzw Limburgs Oncology Centre is a cooperation between Jessa Ziekenhuis, Hasselt and Ziekenhuis Oost-Limburg, Genk in radiotherapy.
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1. LOC
Jessa Ziekenhuis: 3 linacsConventional SimulatorCT-Simulator (Big Bore)PET-CT-Simulator (Big Bore)Planning
Ziekenhuis Oost-Limburg:
2 linacsPlanning
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1. LOC
Core mission:
The delivery of a high qualitative radiotherapy treatment in the
Limburg-region.
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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)
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2. Why Patient Safety?
BVRO/VVROROSIS (Radiation Oncology Safety Information System)
MAASTRO clinicsAdverse events mediaInitiatives in partner hospitals
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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
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3. Approach
2009
Q1 Q2 Q4Q3
Start project
Education/ Literature research
2010
Bench-marking
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3. Approach
2009
Q1 Q2 Q4Q3
Start project
Education/ Literature
search
2010
Bench-marking
Start-up Patient Safety Team
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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)
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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
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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
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3.3.1 PRISMA
Incident Patient Safety Team(Multidisciplinary)
Improvements
Main Causes
Petra Reijnders, MAASTRO 2010
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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
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3.3.2 SAFER
Patient Safety Team(Multidisciplinary)
Design, concept
of process
SAFEROrder, severity
and changeImprovements
“What can go wrong?”
Petra Reijnders, MAASTRO 2010
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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
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Incident reporting Team PatientSafety
PRISMA analyse
Classification main causes
Actions to improve the process
Feedback
3.2 Patient Safety team
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3. Approach
2009
Q1 Q2 Q4Q3
Start project
Education/ Literature
search
2010
Bench-marking
Start-up Patient
Safety team
Internal Reporting
System
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3.3 Internal reporting System
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3. Approach
2009
Q1 Q2 Q4Q3
Start project
Education/ Literature
search
2010
Bench-marking
Start-up Patient Safety team
Internal Reporting System
MotivationCommunication
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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
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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
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3.5 Patient Safety Commission
Report commission
Analyses of (near-)misses on the floor
Involve the reporter
Context (near-)miss
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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
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4. Data
0
10
20
30
40
50
60
70
80
Jan Feb Ma Apr Mei Jun Jul
Quality issue
Near-miss
Miss
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4. Data
Severity
0
2
4
6
8
10
12
14
16
18
No Small Moderate Big Severe
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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
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5. Conclusion
What did we learn?
Analyses of every reportFocus on the system, not on peopleInvolve the reporterClear feedbackPatient Safety CultureContinuous education
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5. Future
Prisma-analysesNew techniques: SaferSelective treatment checkVisitationsSafety awareness trainingRCA/SIREInvolve patients
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Thank you for your attention!