1. Patient Safety in Radiation Oncology Welcome and Introduction Joanne Cunningham Geoff Delaney

3. Why patient safety? First do no harm... Recent studies Acute care Radiation oncology

4. Study / CountryDefinition of A ESampleAdverse Events ACUTE CARE -- RETROSPECTIVE CASE RECORD ANALYSIS US (1984) Harvard Medical Practice Study Death/serious disability 30121 pt records; 51 acute hospitals NY State 2.9-3.7% of admissions; 70% preventable Quality in Australian Healthcare Study (1991) Injury 14179 pt records; 31 hospitals 16.6% of admissions; 51% preventable UK (1998) Adverse Events in British Hospitals Injury Pilot study; 1014 2 hospitals 10.8% of admissions; [incl. 3.5% moderate/serious disability or death] 50% preventable Utah and Colorado Medical Practice Study (1992) Death/serious disability 14052 pt records; 28 hospitals 2.9% of admissions (50% preventable)

5. Medical error Human Cost US 1997, 33.6 million acute admissions => 44,000 to 98,000 patients died due to medical errors (mva 43K, breast ca 42K, AIDs 16K) Harvard Medical Practice Study Economic Cost $8.8bn in the US £1bn a year in the UK in terms of additional bed days alone 8% of all hospital bed days in Australia Estimates based on sentinel studies 5

6. RADIATION ONCOLOGY EXAMPLES Author / JournalMethodologyResults Marks et al; IJROBP 2007;69(5):1579-86 Deviation reporting0.1% Huang et al IJROBP 2005;61(5):1590-5 Incident reports, 5 years 1.97% 555 reports / 28136 patient treatments Yeung et al. RO 2005;74:283-91 Incident reports, 10 years 4.66% 624 incident reports / 13385 patients Macklis et al. J of Clin Oncology 1998;16:551-6 Transfer errors resulting in incorrect treatment 1 year 3.07% 59 errors / 1925 patients Fiorino et al RO 2000;56:85-95 In-vivo dosimetry and Independent check of MU calc & tx chart; No R&V 2.13% of patients with serious systematic error incl. 1.05% >10% dose discrepancy Calandrino et al RO 1997;45:271-4 In-vivo dosimetry 6272 measurements No R&V 4.34% 70 serious and 147 minor errors / approx 5000 pts Barthelemy-Brichant et al RO 1999;53:149- 54 Experimental approach, disabled R&V - frequency of errors in tx settings (not couch settings) 3.22% of treated fields - (1.17% due to R&V input)

7. Improvement necessary With hindsight, it is easy to see a disaster waiting to happen. We need to develop the capability to achieve the much more difficult - to spot one coming DoH UK 2001; An Organisation with a Memory Safety Culture: system improvement, reporting and learning, compliance, communication

8. Why patient safety? Health care = risk to patients Improve the quality of care delivered to the patient Focus on identification and prevention of these failures in complex health care systems Successes E.g. Anaesthesiology, mortality reduced x20 in past 25 years

9. ROSIS & Patient Safety Incidents can have serious consequences in radiotherapy Information about incidents is generally not shared between radiotherapy departments Lost opportunities to learn from incidents and prevent injury to future patients ROSIS established in 2001 To be proactive rather than reactive

10. Radiation Oncology Practice Standards (Tripartite Agreement)

11. Aims of this workshop To assess the impact of mistakes, and methods of prevention, detection, and correction To heighten awareness of the occurrence of incidents and near incidents in radiotherapy To encourage a culture of openness in relation to incidents, and promote collaboration 11

12. Format Lectures Discussion time Group exercises and feedback sessions INTERACTIVE PRACTICAL as well as theoretical Real-life challenges and solutions!

15. Feedback Feedback sheet Fill in (ANONYMOUSLY) as we go along Feedback on scope, contents, format and execution Hand in at the end of the workshop

16. Thanks to our sponsors

17. On behalf of........................Welcome! National Organising Committee Mr Anthony Arnold, NSW Dr Joanne Cunningham, VIC Prof Geoff Delaney, NSW Dr Dion Forstner, NSW Prof Chris Hamilton, VIC Ms Caryn Knight, NSW Prof Tomas Kron, VIC Ms Legend Lee, NSW Mr Leigh Smith, VIC Ms Natalia Vukolova, NSW Mr David Collier, VIC Faculty Mr Anthony Arnold, NSW Ms Fifine Cahill, ACT Prof Mary Coffey, IRELAND Dr Joanne Cunningham, VIC Prof Geoff Delaney, NSW Prof Chris Hamilton, VIC Dr Ola Holmberg, AUSTRIA Prof Tomas Kron, VIC Prof Tommy Knöös, SWEDEN Dr James MacKean, QLD Dr Ivan Williams, VIC