IAEA International Atomic Energy Agency International Reporting
Systems Ola Holmberg, PhD Head, Radiation Protection of Patients
Unit Radiation Safety and Monitoring Section NSRW International
Atomic Energy Agency - IAEA Vienna, Austria Patient Safety in
Radiation Oncology, Melbourne 4-5 October 2012
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IAEA 1. Background: 2 international reporting systems 2.
Detailed look at ROSIS 3. Detailed look at SAFRON Contents
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IAEA 1. ROSIS (Radiation oncology safety information system)
International web-based voluntary incident reporting system in
radiotherapy Developed by a small group of health professionals in
Europe Supported by ESTRO in the initial development stages
Background: 2 international reporting systems
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IAEA 2. SAFRON (Safety in radiation oncology) International
web-based voluntary incident reporting system in radiotherapy Under
development by the IAEA To be released (following pilot-study)
later in 2012 Background: 2 international reporting systems
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IAEA Why 2 international reporting systems? SAFRON is funded
through a regular budget in a major international organization
ROSIS has so far been mainly based on voluntary work (and some
funding through e.g. safety courses) ROSIS might have the
opportunity to work more closely with commercial companies /
manufacturers SAFRON has to be much more restrictive in this area
due to its setting in the United Nations The main point is that the
two systems are in collaboration, sharing information, and working
towards the same goal of patient safety Background: 2 international
reporting systems
IAEA Aims and objectives of ROSIS By enabling RT departments to
share and view reports on incidents By collecting and analysing
information on the occurrence, detection, severity and correction
of RT incidents By disseminating the results and promoting
awareness of incidents and a safety culture in RT
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IAEA Use of ROSIS 8
Slide 9
IAEA Department statistics of ROSIS 150 Departments registered
worldwide Europe 91 departments representing 16 countries Africa,
Asia, Australia, North America/Canada, South/Central America Up to
24 departments per region
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IAEA Department demographics (2011) 426 Linear Accelerators
(mean 3 per Department) 55 Cobalt Machines (mean 0.4 per
Department) 145 Brachytherapy machines (mean 1 per Department)
Patient population of approximately 210,000 new patients per year
(mean 1400 per Department) Department statistics of ROSIS
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IAEA Department information in ROSIS
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IAEA Incident information in ROSIS
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IAEA Incident information in ROSIS 1074 reports External Beam
RT 97.7% (1049) Brachytherapy 1.9% (20) Other modalities 0.5% (5)
(mainly non-process) Who detected?
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IAEA Incident information in ROSIS Detected how?
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IAEA Incident / near-incident 576 (51%) reports: some incorrect
treatment delivered Outcome 86% of incidents affected 1 to 3
fractions Incident information in ROSIS
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IAEA Incident information in ROSIS Type of information
recorded
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IAEA Incident information in ROSIS
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IAEA Incident information in ROSIS
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IAEA Incident information in ROSIS
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IAEA Process steps 4 levels Incident information in ROSIS
IAEA Safety in Radiation Oncology (SAFRON) Expected properties
of the system: Enables learning from incidents and near incidents;
Is dynamic and applicable in a wide range of settings; Can take
account of new technology or processes; Supports education &
training; Enables easy sharing of information and feedback;
Integrates retrospective reporting and prospective risk analysis;
Integrates with existing systems, complementing national and
mandatory systems; SAFRON
Slide 26
IAEA Safety in Radiation Oncology (SAFRON) Properties of the
system in pilot-phase: SAFRON collaborates with other reporting
systems, and currently contains incident information gathered by
the IAEA and ROSIS SAFRON has over 1100 incidents and near misses
in its database SAFRON is non-punitive, anonymous, and voluntary
SAFRON is a comprehensive source of information for radiation
safety related events SAFRON includes information on a wide variety
of published scientific journals and incident reports SAFRON
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IAEA SAFRON
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IAEA SAFRON Output Local info Targeted guidance Incident
reports Other systems Other info Input SAFRON information flow
Shared info
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IAEA Safety in Radiation Oncology (SAFRON) SAFRON will be put
on http://rpop.iaea.org Dedicated website on radiation protection
of patients reaching >1 million hits per month, targeting health
professionals and other stakeholders SAFRON
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IAEA SAFRON
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IAEA SAFRON
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IAEA SAFRON
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IAEA SAFRON
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IAEA SAFRON
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IAEA
Slide 36
New feature to be introduced in SAFRON: Safety Barriers Which
safety barriers did NOT find the incident? Which safety barrier
found the incident? If this safety barrier had not found the
incident, which of your subsequent barriers might have found it?
SAFRON Safety Barrier 1Safety Barrier 2Safety Barrier 3 Patient
Incident Safety Barrier 4
Slide 37
IAEA New feature to be introduced in SAFRON: Safety Barriers
Overall available safety barriers to be queried in Registration
form (check-boxes) Relevant safety barriers in context of incident
to be queried in Incident Report form Might influence reporter to
think about defence-in-depth, effectiveness of safety barriers, and
what safety barriers are in place for safety critical steps SAFRON
Safety Barrier 1Safety Barrier 2Safety Barrier 3 Patient Incident
Safety Barrier 4
Slide 38
IAEA New feature to be introduced in SAFRON: Safety Barriers
Example: Wrong SSD used for manual inverse square calculation of MU
for manually calculated patient plan SAFRON Independent calculation
check Time-out Diode measurement Patient Wrong SSD in calculations
Weekly chart check
Slide 39
IAEA New feature to be introduced in SAFRON: Safety Barriers
Example: Wrong SSD used for manual inverse square calculation of MU
for manually calculated patient plan Which safety barriers did NOT
find the incident? SAFRON Independent calculation check Time-out
Diode measurement Patient Wrong SSD in calculations Weekly chart
check
Slide 40
IAEA New feature to be introduced in SAFRON: Safety Barriers
Example: Wrong SSD used for manual inverse square calculation of MU
for manually calculated patient plan Which safety barrier found the
incident? SAFRON Independent calculation check Time-out Diode
measurement Patient Wrong SSD in calculations Weekly chart
check
Slide 41
IAEA New feature to be introduced in SAFRON: Safety Barriers
Example: Wrong SSD used for manual inverse square calculation of MU
for manually calculated patient plan If this safety barrier had not
found the incident, which of your subsequent barriers might have
found it? SAFRON Independent calculation check Time-out Diode
measurement Patient Wrong SSD in calculations Weekly chart
check
Slide 42
IAEA Strengths of SAFRON Ease of use Funding available Manpower
available IAEA has global reach IAEA has well-established record in
safety activities IAEA is seen as independent IAEA is well-placed
to target guidance to all relevant stakeholders Opportunity to
place system on much visited web-site (rpop.iaea.org) System
developed in parallel with radiological system Opportunity to place
maintenance with professionals Good connection with other
initiatives might serve as meta-system Can to some extent serve as
both global and local system Available for general use: Probably
before December 2012
Slide 43
IAEA Live demo of ROSIS and SAFRON http://www.rosis.info/
https://rpop.iaea.org/SAFRON/Default.aspx
