Program Information
Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)
R Kapoor1,2*, G Malik3 , J Palta1,2 , M Hagan1,2 , (1) Veteran Health Administration, Richmond, Virginia, (2) Virginia Commonwealth University, Richmond, VA, (3) TSG Innovations Inc.
Presentations
SU-E-T-469 (Sunday, July 12, 2015) 3:00 PM - 6:00 PM Room: Exhibit Hall
Purpose:
This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.
Material and Methods:
VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc.
This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process.
Results:
Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts.
Conclusions
Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of “Effecting Quality While Treating Safely”.
Funding Support, Disclosures, and Conflict of Interest: RIRAS developed and copyrighted by TSG Innovations Inc.
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