TU-CD-BRD-03: UCSD Experience, with Focus On Implementing Change

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: • How to create a system that is easy for front line staff to access • How to motivate staff to report • How to promote the system as positive and educational and not punitive or demeaning • How to organize the team for reviewing and responding to reports • How to prioritize which reports to discuss in depth • How not to dismiss the rest • How to identify underlying causes • How to design corrective actions and implement change • How to develop useful statistics and analysis tools • How to coordinate a departmental system with a larger risk management system • How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: 1. Learn how to promote the use of an incident learning system in a clinic. 2. Learn how to convert “event reporting” into “incident learning”. 3. See examples of practice changes that have come out of learning systems. 4. Learn how the RO-ILS system can be used as a primary internal learning system. 5. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.