SAFRON Ola Holmberg Radiation Protection of Patients Unit Division - - PowerPoint PPT Presentation

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SAFRON Ola Holmberg Radiation Protection of Patients Unit Division - - PowerPoint PPT Presentation

Jan 31, 2024 285 likes •518 views

SAFRON Ola Holmberg Radiation Protection of Patients Unit Division of Radiation, Transport and Waste Safety IAEA International Atomic Energy Agency Safety reporting and learning how? Voluntary safety reporting system: Setting

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IAEA

International Atomic Energy Agency

SAFRON

Ola Holmberg

Radiation Protection of Patients Unit Division of Radiation, Transport and Waste Safety

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IAEA

Safety reporting and learning – how?

Setting

  • Voluntary safety reporting system:
  • “Setting in an organization that has a regulatory and

enforcement role for the activity discourages trust and use of reporting”

  • “Independent third party should administer the program

and fulfil the role of an honest broker attending to the interests of both sides”

NB! Mandatory safety reporting to authorities still needs to be done for certain types of events, as defined by the authorities!

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IAEA

Safety reporting and learning – how?

What makes safety reports meaningful? “the narrative”

Charles Billings (the designer of the Aviation Safety Reporting System in the USA)

There is no substitute for knowing why a system failed or why a human erred!

Contents

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SAFRON

  • Retrospective risk

analysis: Safety in Radiation Oncology (SAFRON)

  • Safety reporting and

safety learning system for radiotherapy developed by the IAEA and made available for general use in December 2012

  • Voluntary and

anonymous reporting for radiotherapy centres internationally

  • Register through link on

rpop.iaea.org

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SAFRON

  • Safety in Radiation

Oncology (SAFRON)

  • Learn from radiotherapy

safety-related learning events (incidents and near-misses)

  • Contribute events to the

system for others to learn from

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SAFRON

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SAFRON

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SAFRON

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SAFRON

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SAFRON

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Safety reporting and learning – what?

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Common understanding of parameters for safety reporting systems Severity grading; Causes / contributing factors classification; Standardized process map; Other terminology

Imaging Volumes Planning Review Prescription Trearment (1-n) Accelerator Treatment finished Treatment starts TPS CT, PET/CT, MR ...

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Safety reporting and learning – what?

Process steps WHO U.K.

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Severity scale Canada

Safety reporting and learning – what?

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Safety reporting and learning – what?

Many other parameters ROSIS

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Safety reporting and learning – what?

Why so many parameters in common with other systems?

SAFRON

Output

Local info Targeted guidance Incident reports Other systems Other info

Input

Shared info

e.g. IAEA, ROSIS, ASN, …

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SAFRON next developments

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SAFRON next developments

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Access to SEVRRA-SAFRON

SAFRON next developments

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Access to SEVRRA-SAFRON

SAFRON next developments

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SAFRON next developments

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IAEA

Upcoming

  • Next steps for SAFRON:
  • SEVRRA-SAFRON
  • Brachytherapy
  • More regular feedback