IAEA Technical Meeting on Strengthening of Safety Culture in Radiotherapy through the Use of Incident Learning Systems

The Technical Meeting objectives were to provide Member States, International, Regional and National Organizations an opportunity to evaluate and discuss the use of incident learning systems and how the information can be used to strengthen safety culture in radiotherapy. The meeting explored methods of using incident learning systems, how they can be improved and how they can strengthen Safety Culture in Radiotherapy. The meeting was attended by 50 professionals from 41 countries and seven professional organizations. The participants included regulators, physicists, physicians and radiotherapy technologists from Asia, Europe, Africa, North America, and South America. The meeting allowed the sharing of ideas and activities in an effort to strengthen safety culture in radiotherapy. Participants heard about the many different incident reporting and learning systems available from around the world and how they are using the information to disseminate information to the radiotherapy community. Outcomes of the meeting and future activities include the continuation of sharing information about events and improvements in the processes and how to identify and share best practices at the local, national regional, and international level to improve patient safety in radiotherapy.

The program was broken down into four sessions including:

1. Accidents do Happen,
2. Reporting and Learning Systems,
3. Efforts to Prevent Errors, and
4. Impact on the Use of Incident Learning Systems on Strengthening Safety Culture.

AAPM and CRCPD were able to lend our knowledge of defining an event and our experience with collecting and analyzing radiotherapy events. In addition, AAPM provided information on RO-ILS and TG100 while CRCPD provided information on inspections for the past six years from the USA state reporting programs. Hintenlang also participated in a panel on how the safety culture of a facility can be important to event reporting.

In Session 1, "Accidents do Happen," several presenters discussed major events that have occurred worldwide. These events and the follow up after have led to regulatory event reporting in many countries. In addition, many societies have advocated the use of Incident Learning Systems (ILS) to use at the local level as a way for facilities to track "good catches" and discuss improvements. There were discussions on how tracking events both nationally and internationally can lead to safety improvements in equipment and procedures. At a minimum, it was determined that it would be beneficial if all reportable events were input into IAEA's SAFRON (a web-based voluntary safety reporting and learning system for radiotherapy) at the international level to look for trends and potential issues.

Session 2, "Reporting and Learning Systems," was broken down into two parts:

1. Required Reporting and
2. Voluntary Incident Learning Systems

In the required reporting portion, several presenters, including AAPM and CRCPD, discussed how their country collects and shares events. Most of the countries seem to be collecting the same types of events using somewhat different methods. Several countries disseminate lessons learned via newsletters to give examples of the types of events that are being reported and to encourage reporting to the national regulatory agency. In the discussion of voluntary ILSes, many ILSes were discussed. The sharing of information from voluntary ILSes is important. Discussions were held on how to improve the narrative in ILSes reports so that enough information is provided to make useful determinations on causes and move forward with improvements. Although the ILSes should be set up so that it is user friendly at the local level where the information is being supplied, there are minimum fields that are important so that events, near events, and good catches can be compared whether that be at the local, national or international level.

In Session 3, "Efforts to Prevent Errors", the group discussed how the safety culture concept can and should relate to event reporting and the use of ILS. Several presenters gave examples of how safety culture relates to radiation safety and to medicine in general. There was discussion on gaps in training and for outreach in error prevention. The concept of getting "buy in" at all levels including the regulatory level is important.

The final session, "Impact of Incident Learning Systems on Strengthening Safety Culture", was a wrap up for the meeting. The importance of strong leadership including having a "physician champion" was discussed. In addition, the role of professional organizations in promoting the use of ILSes and in providing ways for each level of participant in radiotherapy to promote safety culture was discussed. The group finished with reviewing potential activities for collaboration and suggestions for strengthening safety culture.

We'll be participating in a similar special interest session so mark your calendar for the 50th anniversary meeting of the CRCPD May 21-24, 2018 in Charleston, South Carolina, a wonderful venue with a history worth discovering. AAPM will also be providing training on Shielding-Up Close and Personal with the assistance of Ken Vanek, PhD and Russ Ritenour, PhD at the Medical University of South Carolina. To celebrate the special relationship between AAPM and CRCPD, in addition to presentations by AAPM President Bruce Thomadsen and GRAC Chair Bette Blankenship, AAPM is also providing a session on Medical Physics: Past, Present and Future. Meeting details can be located at www.crcpd.org.