Radiotherapy Incident Reporting and Learning System
- • One of our current projects entails a radiotherapy incident reporting and learning system. Participation in the system would serve as clients’ input into a national event database and could also serve as their local, institutional radiotherapy event database. A client’s staff could report events, near events and hazardous conditions, with a medical physicist and an industrial engineer, both with experience in event analysis, reviewing the reports and making recommendations. The database would be fully compliant with the AAPM-ASTRO Event Database Recommendations.
- • Reports from clients would be confidential for the reporter. CARS would know the reporter’s identity to allow contact for clarification of details and follow-up, but the facility would not know the reporter. Report of the incident and analysis would go to the client with recommendations. Anonymous reports would be accepted from non-client facilities.
- • For those facilities wishing to perform their own root cause analysis, we are working on implementing a package to walk the analyst through the process. In addition, the package will have modules to assist in making process maps, performing failure modes and effects analysis (FMEA), making fault trees and using these to guide the development of quality management programs.
- • There is also a package that assists in a semi-automatic analysis of quality for image-guided radiotherapy that evaluates positioning of a patient each session and the effect on the dose distribution.
- • We are working to allow automatic forwarding of the information from the events (with the client’s permission) to other databases of either scientific or regulatory nature.
- • The database would allow access to researchers to the deidentified data.
- • Weekly summaries of events and analyses would be sent to the radiological community.
Human Factors Analysis for Manufacturers
CARS provides analysis of quality and safety from a human factors perspective for manufacturers of radiological equipment. Particular attention is given to user interfaces, backup and interlock capabilities and to quality management approaches.
Quality and Safety Training
To help facilities and manufacturers foster and incorporate safety and quality practices, CARS provides training in techniques such as failure modes and effects analysis. Mentoring of the quality leadership in radiological facilities is also a service CARS provides.
To help spread information on quality and safety, CARS hosts web sites on which model process maps and charts, FMEAs and fault trees may be posted after review by a screening committee. The website will also have the ability for chats about quality and safety issues.
More details to follow...