Program Information
Design and Implementation of a National Radiotherapy Incident and Device Reporting System
B Thomadsen1,2*, J Palta1,3,4 , T Mackie1,2 , F Rath1,2 , R Kapoor3,4 , (1) Center for the Assessment of Radiological Sciences, (2) University of Wisconsin, Madison, WI, (3) Virginia Commonwealth University, Richmond, VA, (4) VCU Health System, Richmond, VA
Presentations
PO-BPC-Exhibit Hall-13 (Saturday, March 7, 2015) Room: Exhibit Hall
Purpose: To design and implement a national incident reporting system for radiotherapy.
Methods: The design of the reporting system made use of:
1. Experience in both industrial and medical event reporting;
2. The dataset taxonomy generated by the AAPM-led panel; and
3. Proven methods to avoid several common problems in such systems:
a. Incomplete data due to data-entry fatigue on the part of the person entering the data,
b. Missing data from asking question for which the response requires data that is difficult to obtain or not familiar to most respondents, such as taxonomic classifications.
c. Missing reports due to fear of reprisal.
d. Selection bias for incidents entered into the larger, national database.
Results:1. The system is organized so a person from a facility could notify the database agents through a very brief, on-line application, either as an official reporter of an event or anonymously. Anonymous reporters can give contact information with a guarantee of confidentiality.
2. An agent for the database calls the facility and completes the data entry for the facility while discussing the details of the incident. This not only ensures data completion but also helps the analyst understand the event.
3. Off-line, the analyst performs a root-cause-analysis and drafts a report with suggested actions to improve quality and safety.
4. The analyst discusses the proposed actions with the facility to assess the practicality in the given setting and together generate an action plan.
5. While the facility uses its reports for its local database, all the incidents go into the national database, for which the de-identified data is searchable.
6. The system also includes reporting for equipment problems, and leads to working with vendors to address device issues.
Conclusion:With the design and implementation of the system, the clients are supported and data managed robustly.
Funding Support, Disclosures, and Conflict of Interest: Partial funding for the software development came from TSG Integrations.
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