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Program Information

Hands-On Workshop: Using Incidents to Improve Patient Care


G Kim

J Johnson

L Schubert




G Kim1*, J Johnson2*, L Schubert3*, (1) University of California, San Diego, La Jolla, CA, (2) UT MD Anderson Cancer Center, Houston, TX, (3) Univ. of Colorado Denver, Aurora, CO

Presentations

SU-C-BRA|B-0 (Sunday, March 19, 2017) 2:00 PM - 4:00 PM Room: Ballroom A|B


The Radiation Oncology Incident Learning System (RO-ILS) was introduced to the Radiation Oncology community in 2014. Additionally, many clinics have established and operated local incident learning systems. Often, as part of an interdisciplinary team, physicists are assigned as a department’s quality management expert. The physicist’s role is crucial due to their understanding of the systems involved. When investigating an incident, the physicist should be aware of the clinical circumstances under which incidents occur and the relationship to any systems used in the department. Also, the physicist should play a key role in the incident resolution process. This session aims to provide a comprehensive review of best practices for incident resolution.

This session will present all components of managing an incident learning system. The session will cover 3 follow up tasks consisting of Root Cause Analysis, Classification, and Corrective Action Plan. Attendees will apply these skills in a hands-on exercise. Each speaker will introduce principles and demonstrate with practical clinical examples. Through this hands-on session, attendees will be able to learn about and discuss the application of incident report follow up, incident classification, development of corrective action, staff feedback and outcome measurement using an example scenario.

Learning Objectives:
1. Deconstruct an incident using root cause analysis (RCA)
2. Categorize an incident using incident classification
3. Generate and evaluate a corrective action plan and its components
4. Relate to other team members throughout the process


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