ASTRO/AAPM Radiation Oncology Incident Learning System (ROILS) Todd - - PowerPoint PPT Presentation

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ASTRO/AAPM Radiation Oncology Incident Learning System (ROILS) Todd - - PowerPoint PPT Presentation

Mar 15, 2023 347 likes •599 views

ASTRO/AAPM Radiation Oncology Incident Learning System (ROILS) Todd Pawlicki, Ph.D. Dept of Radiation Medicine & Applied Sciences University of California, San Diego Joint IAEA-ICTP training on patient safety in radiotherapy Trieste,

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SLIDE 1

ASTRO/AAPM Radiation Oncology Incident Learning System (RO•ILS)

Todd Pawlicki, Ph.D. Dept of Radiation Medicine & Applied Sciences University of California, San Diego

Joint IAEA-ICTP training on patient safety in radiotherapy Trieste, Italy 24 – 28 November, 2014

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SLIDE 2
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SLIDE 3

ASTRO’s 6-Point Plan

  • 1. Create a database for RT error reporting
  • 2. Develop a new practice accreditation program
  • 3. Expand quality and safety education/training
  • 4. Develop tools for patients
  • 5. Further develop interconnectivity compliance
  • 6. Advocate for expanded legislation
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SLIDE 4

Why create a national ILS?

Incident: March 2005 Public knowledge: January 2010

1

Incident: March 2008 Public knowledge: September 2013

2

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SLIDE 5

Other Benefits of an ILS

  • Safety improvement (data-based)
  • Better insight into processes

– “I did not know that!”

  • Resource and effort allocation
  • Whether or not quality/safety interventions work
  • Positive staff experience
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SLIDE 6

A National U.S. Error Database

  • 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)

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SLIDE 7

Patient Safety Organization (PSO)

  • An entity listed by AHRQ that meets PSQIA requirements
  • A way to operationalize the PSQIA for healthcare entities

www.claritygrp.com

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SLIDE 8

The ASTRO/AAPM System

Provider Database Analysis and Reports Send to PSO Database Analytics and Analysis by RO-HAC

Provider’s PSES Clarity PSO PSES National Safety Alerts and Reports

PSO: Patient Safety Organization PSWP: Patient Safety Work Product PSES: Patient Safety Evaluation System

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SLIDE 9

RO•ILS Home Page

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SLIDE 10

RO•ILS Event Submission

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RO•ILS Event Submission

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SLIDE 12

RO•ILS Follow-up

  • Identify contributing factors
  • Add additional information
  • Record corrective actions
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SLIDE 13

Status of the RO•ILS

  • Released June 19, 2014
  • Beta testing began in September 2013
  • 19 signed contracts covering 26 sites*
  • 29 contracts pending (will add an additional 41 sites) *
  • Academic and community centers
  • Currently free to ASTRO and AAPM members
  • Rad Onc Healthcare Advisory Council (RO-HAC)
  • MD, PhDs, RTT, Administrator
  • Procedures still in progress …

*as of 9 September 9 2014

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SLIDE 14

Encourage All Reporting

  • Major events
  • Minor frequent events
  • Near-misses
  • Unsafe/Unexpected conditions
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SLIDE 15

43% 33% 23% 1% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Incident Near-miss Unsafe condition Not patient related

Percentage total responses

N = 145 as of 15 October 2014

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SLIDE 16

13% 1% 1% 1% 2% 8% 14% 28% 32% 0% 5% 10% 15% 20% 25% 30% 35% Unknown Other Physician Resident Radiation Oncologist Other Attending Radiation Oncologist Administrator Dosimetrist Physicist Radiation Therapist

Who reported the event? (percentage total responses)

N = 145 as of 15 October 2014

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SLIDE 17

139 4 2 20 40 60 80 100 120 140 160 External Beam Other Brachytherapy

Type of Event (total count)

N = 145 as of 15 October 2014

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SLIDE 18

43 1 1 1 1 1 2 4 5 6 9 11 20 49 10 20 30 40 50 60 Unknown Not Applicable Protons or other particles Intracavitary HDR Cranial SRT/SRS Total Body Irradiation (TBI) Modulated Arc Electrons SBRT Other 2D IMRT 3D

Treatment Technique (total count)

N = 145 as of 15 October 2014

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SLIDE 19

57% 12% 30% 0% 10% 20% 30% 40% 50% 60% 70% No Yes Unknown

Did event occur with other patients? (percentage total responses)

N = 145 as of 15 October 2014

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SLIDE 20

Successful Incident Learning

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  • Part of quality/safety improvement program

– Explicit support from leadership

  • System for reporting and guidelines

– Share data and provide feedback

  • Competence to interpret reported data

– Ability to make process changes

  • Appropriate organizational culture

– Reporting and Just cultures

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SLIDE 21

Organizational Culture

  • Shared values and beliefs produce behavioral

norms

– Shared values → What is important – Shared beliefs → How things work

  • Safety culture

– Reporting culture – Just culture

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SLIDE 22

Reporting Culture

  • Efficient method to submit all event types
  • Indemnity against retribution for reporting
  • Separate data collection from those with authority to discipline
  • Feedback to the reporting community
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SLIDE 23

Just Culture

  • Not all errors result from acceptable actions
  • Blanket immunity is not appropriate
  • Establish performance standards and

expectations of behavior

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SLIDE 24

Summary

  • RO-ILS is a national incident learning system for

the U.S.

  • Should be implemented within the appropriate
  • rganizational culture