Program Information
VA Radiotherapy Incident Reporting and Analysis System (RIRAS): The True Learning System
R Kapoor1,2*, M Hagan1,2 , J Palta1,2 , (1) National Radiation Oncology Program- VA Central Office, Richmond, VA, (2) Virginia Commonwealth University, Richmond, VA
Presentations
TU-FG-702-11 (Tuesday, August 1, 2017) 1:45 PM - 3:45 PM Room: 702
Purpose: To demonstrate the impact of RIRAS on learning in radiation oncology from the adverse event and good catch data.
Methods: Anonymous Incident Reporting Systems (IRS) are and will continue to be an important patient safety arsenal. However, a major limitation of an anonymous report is that the learning is diminished if the reporter’s narrative lacks details. The process of radiotherapy is fairly complex and it has several error pathways, which often not covered in are any written narrative and can only be discerned via direct communication between the reporter and the analyst. RIRAS, a Web-based onymous incident learning system was deployed at VA in May, 2014. Over 300 reports have been entered into the system. All reports have been analyzed by a radiation oncology subject matter expert (SME). In almost all cases (> 90%), more information was sought from the reporter to correctly analyze the error type, medical and dosimetric severity, interventions and potential causes. For each reported incident, a customized patient safety work product was generated and shared with the reporter. It includes corrective, preventive and learning actions.
Results: We are able to complete causal analysis for 100% of the reported incidents and have made individualized recommendations in each case for process improvement to enhance patient safety. Our analysis of reported incidents from each facility is able to identify the weaknesses of their clinical processes and make specific recommendations for corrective actions.
Conclusion: Early experience with RIRAS demonstrates the importance of following up and gathering complete information on an incident to perform an effective root cause analysis and add value to the reporting facility. Learning from the reported incidents is significantly diminished when the SME analyst does not have the ability to request supplemental information beyond the written narrative.
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