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THE LIVERPOOL SYSTEM - CLASSIFICATION, LEARNING & PREVENTION
Incident Reporting and Learning:
Anthony ArnoldDirector Cancer Services, Illawarra Shoalhaven Local Health [email protected]
--- ROSIS Melbourne Australia 2012 ---
Context
2
--- ROSIS Melbourne Australia 2012 ---
The Liverpool System
3
Ref: IJROBP 2010 Volume 78, No 5, Pages 1548-1554
--- ROSIS Melbourne Australia 2012 ---
A Problem Worth Solving……
Complexity of radiation oncology At the time no system of analysis was
in place Lack of clinical governance surrounding
reporting There was limited openness about
reporting events The culture was predominantly blame
based Standard reporting systems are
ineffective for radiation oncology 4
--- ROSIS Melbourne Australia 2012 ---
ClassificationPrescription
Simulation
Computing / Dosimetry
Pre-Tmt
TreatmentImaging
Bolus
Shielding
Documentation
5
6
Incorrect Tmt Site Prescribed Incorrect Energy Prescribed Incorrect Dose or Dose per Fraction
Bolus not Prescribed when Req’d Shielding not Prescribed when Req’d Prescription not signed by Rad Onc
Other: Prescription Related Incorrect Site Scanned / Simulated Insufficient Scan Area Applied
Incorrect CT Procedure Applied Laser Shift / Related Error Sim Film Marked Incorrectly
Simulation Tattooing Related Error Inappropriate Pt Positioning Used Volume / Voluming Related Error
Landmarking Related Error / Omission Contrast Related Error Other: Simulation Related
Incorrect CT-Density Conversion Used Incorrect Weight/Calc/Dose Point Used Incorrect Normalisation Applied
Other: Computer Planning Error Incorrect MU Calculation Incorrect Detail in R+V System
Tray / Wedge Code Missing / Error Attenuation Factor Missing / Error QA Check/s Not Completed / Error
Treatment Sheet Annotation Error TLD Related Error / Omission Pacemaker Related Error / Omission
Other: Pre-Treatment Related Geographic Miss: Incorrect Site Geographic Miss: FSD/SSD Error
Geographic Miss: Incorrect Tattoo Geographic Miss: Landmarking Error Geographic Miss: Incorrect Fld Used
Geographic Miss: Field Size Error Patient Not Treated When Required Field Not Treated When Required
Incorrect Wedge / Wedge Orientn Incorrect Energy Delivered Changes / amendments not in R+V
Immobilisation Device Error History / Chart Check Missed / Error Other: Treatment Related
Bolus not Applied When Required Bolus Applied to Incorrect Site Incorrect Bolus Material Used
Incorrect Bolus Thickness Used Other: Bolus Related Shielding Not Applied When Req’d
Incorrect Shielding / Cut-out Used Shielding Applied to Incorrect Area Shielding Mounting / Tray Error
MLC Pattern / Related Error MLC File Missing / Not Attached to Fld MLC Checks Missed / Not Done
Other: Shielding Related Image Not taken When Specified Film / EPI Labelled Incorrectly
Image Not Reviewed When Required Iso Adjustments Applied Incorrectly Iso Shifts Not Applied When Req’d
Other: On-line / Off-line Related Documentation Error: Sim Documentation Error: Tmt Sheet
Documentation Error: R+V System Documentation Error: Imaging Documentation Error: Other
Prescription
Simulation
Computing
Pre-Treatment
Treatment
Bolus
Shielding / MLC
Imaging
Documentation
--- ROSIS Melbourne Australia 2012 ---
Classification Advantage
7
--- ROSIS Melbourne Australia 2012 ---
Error / Event Definitions
Event: “event or circumstance which could have
resulted, or did result in harm to a patient”
Actual Error: “Error resulting in radiation exposure other
than that intended or prescribed – correctable or otherwise”
Near Miss: “Error or non-conformance detected
before reaching the patient”
8
--- ROSIS Melbourne Australia 2012 ---
High Level Structure…….PDSA
PLAN
•Classification designed, database constructed, education
•System implementation, clinical leadership and support
DO
•Staff encouraged to report all events irrespective of magnitude
•Supporting governance, openness, process based
STUDY
•Summary reports analysed monthly across various forums
•Trend patterns analysed to highlight areas / systems in need
ACT
•The data itself was used to focus QA and improvement activity
•Focussed education, workflow redesign, protocol changes
9
--- ROSIS Melbourne Australia 2012 ---
Reporting and Managing an Event
Detect
•Staff detecting initiates report (narratives, tells story)
•Manage patient and situation, immediate actions
Review
•Team review, contributing factors, further actions
•Agree on report as a team
Share
•Reverse back through other staff and depts involved
•Learning, prevention, further analysis, additional factors
Manage
•Review and classifiy, explore issues, system breaks
•Consider recommendations, initiate change / improvements
10
--- ROSIS Melbourne Australia 2012 ---
Department AnalysisLiverpool
Macarthur CTC (2004-2007)
Illawarra CCC(2006-2009)
4-5 linear acceleratorsSuperficial / orthovoltage
BrachytherapyWidespread conformal
3DCRTIMRT on horizon
Large metropolitan centre
688 reports / 3925 courses
2 linear acceleratorsSuperficial / orthovoltage
No brachytherapyWidespread conformal
3DCRTIMRT widespread clinical use
Small semi-regional centre
670 reports / 3645 courses11
--- ROSIS Melbourne Australia 2012 ---
Results - Initial Pilot
688 reports were logged during the study period 155 Actual errors (23%) 533 Near Miss (77%)
Attendances
Actual Error Near Miss
Analysis of 1st 3 years of operation (May 2004-May 2007)
12
--- ROSIS Melbourne Australia 2012 ---
Results - Subsequent Pilot
670 reports were logged during the study period 67 Actual errors (10%) 603 Near Miss (90%)
Attendances
Actual Error
Near Miss
Analysis of 1st 4 years of operation (2006-2009)
13
--- ROSIS Melbourne Australia 2012 ---
Time Trends Statistics
Actual Error
Near Miss
Total Errors
No. of Attendance
s
% Actual Error
p-value for
Actual Error Rate
Difference
% Near Miss
p-value for Near
Miss Rate
Difference
% Total Even
ts
p-value for Total
Errors Rate
Difference
Year 1 63 184 247 21788 0.3% 0.8% 1.1%
Year 2 58 199 257 38134 0.2% p<0.01 0.5% p<0.000
1 0.7% p<0.0001
Year 3 34 150 184 55006 0.1% p<0.001 0.3% p<0.000
1 0.3% p<0.0001
Ref: Simple Interactive Statistical Analysis online statistical calculator. Available at: http://www.quantitativeskills.com/sisa/statistics/t-test.htm. Accessed 29 January 2008 14
--- ROSIS Melbourne Australia 2012 ---
Time Trends Statistics
Actual Error
Near Miss
Total Errors
No. of Attendance
s
% Actual Error
p-value for
Actual Error Rate
Difference
% Near Miss
p-value for Near
Miss Rate
Difference
% Total Even
ts
p-value for Total
Errors Rate
Difference
Year 1 16 145 161 6221 0.26% - 2.33
% - 2.59% -
Year 2 12 173 185 15687 0.08% 0.0016* 1.10
%p<0.000
1*1.18
% p<0.0001*
Year 3 27 128 155 17028 0.16% 0.1695* 0.75
%p<0.000
1*0.91
% p<0.0001*
Year 4 12 157 169 15582 0.08% 0.0017* 1.01
%p<0.000
1*1.08
% p<0.0001*Ref: Simple Interactive Statistical Analysis online statistical calculator. Available at: http://www.quantitativeskills.com/sisa/statistics/t-test.htm. Accessed 29 January 2008 15
Time Trends 1st Pilot: Attendances
04/05 05/06 06/07
No. of Attendances 21788 38134 55006
Actual Error 63 58 34
Near Miss 184 199 150
5000
15000
25000
35000
45000
55000
25
75
125
175
225
275
325
375
425
475
Att
en
dan
ces
Inci
den
ts
16
Time Trends – 2nd Pilot: Courses
2006 2007 2008 2009
Total Courses 894 901 946 904
Actual Errors 47 12 27 12
Near Misses 427 173 128 157
50150250350450550650750850950
50
150
250
350
450
550
Pati
en
t C
ou
rses o
f Tre
atm
en
t
Rep
ort
ed
Even
t C
ou
nt
17
--- ROSIS Melbourne Australia 2012 ---
Study Time period
Actual Error Rate per
treatment episode
Total Error Rate per
treatment episode†
Reporting scope
CommentsSimulation Prescription Planning
Treatment delivery
Our study
2004-05 0.3% 1.1%
2005-06 0.2% 0.7%
2006-07 0.1% 0.3%
Macklis et al.[17] 1995
0.2% per treatment
fieldNR x
Block errors most
common
Fraass et al.[24] 96-97 0.4% NR x x x
Treatment set-up and treatment accessory
errors most common
Huang et al.[22] 97-02 0.3% NR x x x
Tight parameters
for error. Treatment
field errors of >0.5cm the
most common.
Calandrino et al.[19] 91-96
0.45% per treatment
course
3.5% per treatment
coursex x x
MU calculations
only
Barthelem-Brichant et
al.[27]
NR 3.5% NR x x x Patton et al.
[6] 99-00 0.2% NR x x x
Swann-D’Emilia[25] 89-90
0.17% per treatment
fieldNR x x x
Most errors were due to
errors in block
placement18
--- ROSIS Melbourne Australia 2012 ---
Outcomes – Key Measures
Reduction in Errors
Reduction in Error
Rate
Improved Patient Safety
19
--- ROSIS Melbourne Australia 2012 ---
Patient Safety Risk Improvement REDUCTION IN REPORTED EVENTS as a function of
attendances Actual Error rate reduced from 0.26% to 0.08%
(p=0.0017) Near Miss rate reduced from 2.33% to 1.01% (p<0.0001)
IMPROVED RELATIVE PATIENT SAFETY RISK per treatment course
Actual error rate reduced from 1 in 19 courses to 1 in 75 courses; in other words from 5% down to 1.3% risk of detectable error (p=0.0003)
Near miss rate reduced from 1 in 2 courses to 1 in 6 courses; in other words from 50% down to 17% (p<0.0001)
20
THANK YOU