Patient Safety

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TU_26_3070 - ASTRO's Radiation Oncology-Incident Learning System (RO-ILS): A Multi-site, Multi-faculty Radiation Department Culture Immersion into RO-ILS

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

ASTRO's Radiation Oncology-Incident Learning System (RO-ILS): A Multi-site, Multi-faculty Radiation Department Culture Immersion into RO-ILS
K. Aronoff1, A. Kapur2, A. C. Riegel3, J. Antone3, G. Somerstein4, M. Lim1, and L. Potters3; 1Phelps Hospital Northwell Health, Sleepy Hollow, NY, 2Department of Radiation Medicine, Northwell Health, Lake Success, NY, 3Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, 4Northwell Health, New Hyde Park, NY

Purpose/Objective(s): The Radiation Oncology-Incident Learning System (RO-ILS) is a web based incident reporting system that provides a global mechanism for collaborative learning within radiation oncology. The RO-ILS mission encourages all members to report events as they happen in the department in a non-punitive environment. In September 2017, our multi-site radiation oncology department converted completely to RO-ILS following a decade of usage of an in-house system. The purpose of this work is to share our preliminary experience with RO-ILS, specifically focusing on comparative trends in event reporting, classification and learning.

Materials/Methods: Between October 2017 and January 2018, events submitted were classified into the following categories: Therapeutic radiation incident, other safety incident, near-miss, unsafe condition, operational/process improvement. A single RO-ILS coordinator reviewed and further characterized these events into the following sub-categories for more detailed analysis and follow up. A multi-disciplinary quality management (QM) team met biweekly to investigate and develop follow-up actions which were communicated to the entire staff at monthly meetings at each geographical site to “close the loop” and demonstrate the effectiveness of event reporting.

Results: In a 4-month time period, staff reported 325 events. The distribution of events was as follows: Therapeutic radiation incident (53), Other Safety incident (10), Near-miss (19), Unsafe condition (5), and Operational/Process Improvement (238). Due to the default categories being too shallow, events were reclassified into: Communication, Prescription and Directive mismatch, Film Review, Re-simulation, New Plan, On Treatment Visit, Dosimeter, Physics, Equipment Malfunction, Information Technology, Patient on Break, Consent, No physicist on site, Patient Safety, Treatment terminated, Physics weekly chart checks not completed, Pathology, SOARIAN error, Scheduling, and Accident.

Conclusion: Event reporting systems serve as an important function in raising awareness and generating a culture of safety. To date, our department has successfully and effectively rolled out RO-ILS and its key components. However, meaningful expansion of default classifications are recommended. RO-ILS allows our team to “track and trend” events, identify root causes, and implement targeted changes to improve patient care. We have provided feedback to the front lines monthly, closing the loop and encouraging further reporting. The frontline staff feels as though their reporting makes a difference, effecting positive changes in the department. As one of the few large multi-site institutions to fully implement RO-ILS, the amount of entries and expanded classifications submitted will provide valuable feedback to the radiation oncology community.

Author Disclosure: K. Aronoff: None. A. Kapur: Vice chair; ASTRO. A.C. Riegel: None. J. Antone: None. G. Somerstein: None. M. Lim: None.

Katrina Aronoff, RT, BS

Biography:
Katrina Aronoff, BS, R.T.T. Chief Radiation Therapist, Phelps Hospital Northwell Health.
· Chief Radiation Therapist
· RO-ILs Leader. Radiation Oncology Incident Learning System
· Teaching Treatment Planning to Radiation Therapy Students for NYMH Center for Allied Health Education
· Administering radiation treatment to 55+ patients a day using photons and electrons to patients of all ages, from infant to 90 year olds, including palliative care
· Advanced experience in CT simulations using Philips Big Bore CT Scanner, TRUE BEAM, Varian Linear Accelerators, VARIAN Trilogy, and Accuray TomoTherapy
· Clinical Preceptor for Radiation Therapy Students at Northwell Health Lenox Hill
· Assisting in ultrasound research of head and neck cancers
· ARRT Credentialed #356132
· ASRT Certified
· NY State Licensed
· BLS Healthcare Provider Adult and Infant CPR-AED
· ACLS Provider Certified
· HeartSaver CPR AED Certified
· US Coast Guard Reserves – Boatswain’s Mate, Petty Officer 3rd Class
· FEMA ICS Class 100, 200, 300, 400, 700, 800 completed

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TU_26_3070 - ASTRO's Radiation Oncology-Incident Learning System (RO-ILS): A Multi-site, Multi-faculty Radiation Department Culture Immersion into RO-ILS



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