Room: AAPM ePoster Library
Purpose: Describe an 18-month journey implementing a Radiation Therapy incident reporting system, emphasizing the role of Medical Physics.
Methods: An incident review team was assembled from department leads and led by a Medical Physicist. Processes were developed and tested prior to implementation, including methods for reporting incidents, triaging reports, and responding to events. Web-based software based on AAPM’s Work Group on Prevention of Errors taxonomy and data dictionary was deployed for reporting, analysis, and data aggregation. The interdisciplinary team met weekly to triage reports, recognize contributors, assign incident analyzers, and identify improvement projects.
Results: 545 reports were reviewed and acted on (including 120 actual events) over a series of 75 one-hour meetings. Severity was scored from D (lowest) to A (highest) based on the potential for harm and the step where caught. Level C and D incidents were most frequent and were addressed using small process clarifications, training, or communication. More serious issues resulted in 18 process improvement initiatives. A simple, common taxonomy for preventative and learning actions was implemented. Reporting led to a major restructuring of the physicians’ intent/prescription as well as substantive changes in Medical Physics checks. During the first 6 months, 89% of the reports were submitted by therapists. One year later, physicists/dosimetrists submitted 86% of the reports, a change attributed to preventative actions implemented earlier in the process and increased reporting. A trend of decreasing severity was also observed; initially 20% were scored A or B, 41% C and 39% D, which then changed to 6%, 21%, and 72% respectively.
Conclusion: An incident reporting system was implemented with Medical Physics in a leadership role, bringing together an interdisciplinary team for clinical error identification, prevention, and process improvement. The resulting changes corrected problems earlier in the treatment process and before reaching the treatment machines.