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PRELIMINARY FINDINGS: Incident Reporting Survey
ROSIS WORKSHOP
Thursday, 4 October 2012
Australian Institute of Radiography, Melbourne
FIFINE CAHILL
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Overview
• Progressing reform in Radiation Oncology
• Developing a Quality Framework• Incident Reporting Survey • Preliminary Results• Next steps
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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
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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.
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Survey Respondents
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1. Incident Reporting Systems
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2. Electronic System Types
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3. Rad. Onc. Specific Module
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4. Classifying Incidents: Conformance
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5. Error levels: Conformance
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6. Rating Incidents: Conformance
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7. Open Reporting
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8. Actioning incidents
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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
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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.