Critical Incident Reporting System (CIRS) at KSA. E.Rabe, G.Lutters, S.Bodis Radio-Onkologie Aarau

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1 Critical Incident Reporting System (CIRS) at KSA E.Rabe, G.Lutters, S.Bodis Radio-Onkologie Aarau

2 Why CIRS? Avoidance of incidents which could potentially damage patents Recognition of unsafe structures which could lead to incidents Gain insight into corrections needed in the future Learn our of errors Senders JW FMEA and RCA: the mantras of modern risk management: Qual Saf Health Care 2004

3 Definition of Critical Incident Incidents which could potentially damage patients Not malpractice Initiates perfection and adaptation of structure and processes Goal: Identification of insufficient structure and unsafe procedures Dr. med.georg von Below, Ressortleiter Qualität; FMH Verbindung Schweizer Ärztinnen und Ärzte

4 Fluss der RT-Planungsdokumente Fach Ort Zw eck Neue Franziska Unterschriebenes Konzept Konzepte Meier für Terminierung und Fax an zuweisenden Arzt / Hausarzt Ordner für Franziska Lagerung der Konzepte und - CT Meier der Lagerungsblätter - Therapax vor der Planungs-CT (- Simulator) Physik- Planungsraum Dosisberechnung Fach (UG) Planung ProSim Rapportraum RT-Protokoll mit technischen Parametern durch MTA Fach für Planungsraum RT-Protokoll vom Planungsarzt (UG) Planungsarzt vervollständigt Physik- Planungsraum RT-Protokoll Fach (UG) Physik-Unterschrift Fächer Rapportraum RT-Protokoll Unterschrift CA/LA/OA CA / LA / OA Fächer Rapportraum Fertig bearbeitete Planungs- Geräte Unterlagen / bereit für Ersteinstellung Geräte 1. Chart-Check Verifikation der RT-Felder 1.RT Geräte 10.RT 2. Chart-Check

5 How do we achieve this? Regular meetings of the QA workgroup

6 QA-AG: What happened? Discussion of information which lead to the incident Why did it happen? Identify all factors which participated in the incident What consequences does a particular fault have on a smooth functioning of the procedure? What can/must be done, to reduce the probability of reoccurrence of this error? How can a process be modified such that it is impossible for the error to reoccur? Senders JW FMEA and RCA: the mantras of modern risk management: Qual Saf Health Care 2004

7 How do we achieve this? Regular meetings of the QA workgroup Every incident must be reported: Incident Report

8 Incident Report When When an incident occurs When an incident could possibly have occurred When insecure actions take place Where Work space where above took place Who Participants and responsible people (not for purposes of accusation, but merely for purposes of source of information)

9 Incident Report What Description of the incident Consequence further procedure

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11 How do we achieve this? Regular meetings of the QA workgroup Incident Report Chart-Check

12 Chart-Check When: Before the first radiation treatment At the tenth radiation treatment Who: Person responsible for the machine / Leading MTRA

13 Chart-Check What Comparison of Paper - concept with verification system Lantis (Siemens) Intended planning and realised plan Documentation of patient positioning with effective positioning Amount of appointments Signatures of CA / planning medic / physics for release of radiation concept

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15 Evaluation of Chart-Check Chart-Check Time from Dec June 05 Count: Total: 477 Correction needed: 221 No correction necessary: 242 Incomplete: 14

16 Evaluation of Incident Reports Incident Reports: Time from Dec June 05 Count: Total: 62 Incidents: 22 ( 0.009% relative to radiation treatments) Count of radiation treatments Count of radiation fields

17 Evaluation Chart-Check / Incident Report Comparison of corrected mistakes relative to Chart-Check count and Incident Report count: Incidents Corrected (Chart-Check) Paper concept with electronic verification system Lantis (Siemens) 26 0 Intended planning relative to actual plan: 38 4 Patient positioning / documentation: 77 1 Appointments: 71 0 Signatures: 14 0 Manual faulty operation of irradiation facilities: 17

18 Consequences of the Incidents Of the 22 incidences, 20 resulted in 1 faulty radiation fraction, 2 resulted in multiple faulty radiation fractions All incidences that only occurred once had no consequence for the patient The incidences with multiple faulty radiation fractions also lead to no consequences for the patient. These errors were calculation errors from the physics department.

19 Consequences of human errors in operation of devices Human errors in operation can not be avoided by Chart-Check. 2 typical errors in operation and possible attempt to avoid them: Flab got forgotten Standard used to be: Flab for half of the therapy, now for the whole therapy Block got forgotten / resp. false block used acquisition of new therapy units which have MLCs

20 Conclusion Due to the two pre-printed forms Incident Report and Chart-Check we could significantly reduce the amount of incidences.