1. National Incident Learning Todd Pawlicki UC San Diego Dept of Radiation Medicine & Applied Sciences ASTRO/AAPM Incident Learning System (RO ILS)

2. Safety Triangle Fatality Severe Injury Minor Injury Near Miss Bad Practices Majority of incidents are here. “Free Lessons”

3. 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

4. A Radiotherapy Example Med Phys 2010 Approximately 0.6 events per treated patient

5. 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

6. 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

7. 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)

8. What is a PSO? An entity listed by AHRQ Operationalize PSIQA for healthcare organizations www.claritygrp.com

9. ASTRO/AAPM ILS Improvement PSQIA Intervention Analysis (ROHAC) Incident or near-miss report Protected Space Anna Marie Hajek President & CEO Clarity Group, Inc.

10. 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 PSWP

11. RO ILS

15. Follow-up Identify contributing factors Add additional information Record corrective actions

16. Status of the RO ILS Currently in beta testing Official release Q1/Q2 2014 Free to ASTRO members Must have contract with Clarity PSO

17. What to Report? Major events Minor frequent events Near-misses Unsafe/unexpected conditions

18. May Still Need Other Reporting Must follow all Federal and State reporting requirements NRC California CA Department of Public Health (CDPH) Radiologic Health Branch

19. 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

20. 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

21. 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