|Author||Kapoor, R. ♦ Palta, J. ♦ Hagan, M. ♦ Burkett, D. ♦ Leidholdt, E.|
|Source||United States Department of Energy Office of Scientific and Technical Information|
|Subject Keyword||APPLIED LIFE SCIENCES ♦ RADIATION PROTECTION AND DOSIMETRY ♦ ACCIDENTS ♦ DOCUMENTATION ♦ FEEDBACK ♦ INFORMATION SYSTEMS ♦ LEARNING ♦ LICENSES ♦ PATIENTS ♦ RADIOTHERAPY ♦ SAFETY ♦ VERIFICATION ♦ WHO|
|Abstract||Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reporting facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly diminished when the analysts do not have the ability to request additional information.|
|Learning Resource Type||Article|
|Publisher Place||United States|
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