PRELIMINARY FINDINGS: Incident Reporting Survey

ROSIS WORKSHOP

Thursday, 4 October 2012

Australian Institute of Radiography, Melbourne

FIFINE CAHILL

Overview

• Progressing reform in Radiation Oncology

• Developing a Quality Framework• Incident Reporting Survey • Preliminary Results• Next steps

Quality Framework

STANDARDSDevelopment of

(or refinement) of Standards or Guidelines

QUALITY IMPROVEMENTSuch as incident

monitoring

ASSESSMENTConformity assessment against

standards

QUALITY ASSURANCESuch as regular

dosimetric auditing

TRIAL: Australian Clinical Dosimetry Service

Incident Reporting SurveyPurpose:

• Collect information about:- incident reporting systems in use- extent of conformance with the reporting

framework proposed in the standards• Inform a status report on incident reporting

Administration • Draft survey piloted with RTAP • Attempted census of all sites (63 sites)• Initial letter. Follow up email with survey link.• NSW public facilities invited by NSW Ministry of

Health.• Survey opened 5 September. Results based on

responses to COB: 21 September.

Survey Respondents

1. Incident Reporting Systems

2. Electronic System Types

3. Rad. Onc. Specific Module

4. Classifying Incidents: Conformance

5. Error levels: Conformance

6. Rating Incidents: Conformance

7. Open Reporting

8. Actioning incidents

Preliminary Results: Key messages

• Respondents have an incident reporting system in place

• Electronic systems vary and many sites use more than one system (electronic and/or paper)

• High degree of conformance with standards framework

• BUT current differences would constrain attempts at national reporting

NEXT STEPS

• Complete full analysis of all responses.• Prepare and publish status report.• Consider findings and possible options

for enabling the aggregation of incident data nationally.