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Program Information

Safety 1: Incident Learning Systems in Radiation Therapy

E Ford

G Ezzell

D Gilley

E Ford1*, G Ezzell2*, D Gilley3*, (1) University of Washington, Seattle, WA, (2) Mayo Clinic Arizona, Phoenix, AZ, (3) AAPM, College Park, MD

SU-A-Salon AB-1 Sunday 7:30:00 AM - 9:30:00 AM Room: Salon AB

Identifying and analyzing safety-related events is a proven way to enhance the quality and safety of care. Data demonstrate that patient outcomes are improved when healthcare providers actively engage in incident reporting. This session will review existing data and discuss how incident learning systems are currently used in radiation oncology. The essential features of incidents and near-misses will be presented along with the criteria for reportable events under the various applicable regulations. The use of incident learning system at the departmental level will be discussed along with recommendations for structuring and operating such systems. Though incident learning is coming into wider use within clinics, there is still a major unmet need to collect and share such information between clinics. This session will highlight one new system designed to enable this: the national Radiation Oncology Incident Learning System (RO-ILS). This system, sponsored by ASTRO and AAPM, provides a means for sharing safety-improvement information with the legal protections afforded by its status as a Patient Safety Organization. Early experiences with this system will be shared, along with experiences from the SAFRON system, an internationally used open incident reporting system.

Learning Objectives:

1. Understand the definitions of events and near-misses and how to structure an incident learning system at the department level

2. Learn about the national effort to establish the national Radiation Oncology-Incident Learning System (RO-ILS)

3. Understand the investigation process and lessons learned with SAFRON, an international incident learning system in radiation oncology


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