VA Radiotherapy Incident Reporting and Analysis System (RIRAS)
|
|
|
- Curtis Godfrey Burke
- 5 years ago
- Views:
Transcription
1 VA Radiotherapy Incident Reporting and Analysis System (RIRAS) Jatinder R Palta PhD Rishabh Kapoor MS Michael Hagan, MD National Radiation Oncology Program(10P11H) Veterans Health Administration
2 Disclosure Vice President, Center for the Assessment of Radiological Sciences (CARS) A non-profit organization dedicated to improving quality and safety of radiotherapy and radiological imaging.
3 Objectives Describe the design characteristics of the infrastructure for radiotherapy incident reporting in the VHA Describe incident reporting workflow Give live demonstration of an incident reporting, analysis, and learning Discuss lessons learned from the VHA incident reporting system
4 VA National Center for Patient Safety Goal Nationwide (151 VA hospitals) reduction and prevention of inadvertent harm to patients as a result of their care Mission Use a "systems approach" to develop health care solutions based on prevention, not punishment. Strategy Use Human Factors Engineering methods and apply ideas from "high reliability" organizations, such as aviation and nuclear power, to target and eliminate system vulnerabilities. Reporting System Patient Safety Information System (over 1M reports) The information PSIS is protected from disclosure under 38 U.S.C
5 Patient Safety Information System Designed to document patient safety information from across the VA in a general hospital setting, e.g. Misdiagnosis Unnecessary treatment Unnecessary tests Medication mistakes Never events Uncoordinated care Infections, from hospital to patients Not-so-accidental accidents Missed warning signs Going home- not so fast Limitations : Lacks Radiation Oncology Taxonomies/Ontologies
6 Incidents Happen We, the radiotherapy community, need to accept that errors do happen. Errors happen when even trying to do a good job, good earnest workers. Errors almost always happen when multiple unusual things happen at the same time. In order to improve the situation, we need to study what happened every time and learn from it..
7 What to Report? Adverse event or incident or any situation that just doesn t seem to go like it is supposed to. These include good catches that may go undocumented because someone caught the problem before anything bad happened. Good catches are great opportunities to identify the weaknesses or failure points in systems and processes that, if not addressed, can lead to bad outcomes.
8 Why Report? Sometimes you may be uncomfortable reporting an error or a good catch. But if reports are not made, we will never be able to fix or improve the system or process that contributed to the error. Intent of reporting incidents or good catches is to prevent similar errors in the future, not to punish any one. Reporting is non punitive.
9 Radiotherapy Incident Reporting and Analysis System* (RIRAS) A reporting system to aggregate data for: Errors regardless of whether they lead to harm (good catches) Adverse events that are recordable at facility level Medical events that are reportable as per regulatory requirement VHA Directive Mandatory Reporting for Misadministration of Therapy Machine Sources of Ionizing Radiation Issues/problems with radiotherapy devices
10 Radiotherapy Incident Reporting & Analysis System (RIRAS) Attributes: Taxonomy and data dictionary based on AAPM document on, Error Reporting, A carefully designed data entry form that minimizes keystrokes (pull-down menus based on well-established clinical workflow for consistent data reporting, pre-filled facility data, etc.), Anonymous reporting option, Relational event database, Data analyses, management and maintenance. RIRAS is on the VA Intranet ( Ford EC et.al. Consensus recommendations for incident learning database structures in radiation oncology, Med Phys 39, 2012
11 RIRAS Workflow Step 1: Initial Report
12 RIRAS Workflow Step 2: Analysis
13 RIRAS Workflow Step 3: Patient Safety Work Product
14 RIRAS Workflow Step 4: Local Process Improvement
15 RIRAS Workflow Step 5: National Process Improvement
16
17 RIRAS Status Report All 39 Radiation Oncology Services in VHA have used the RIRAS to report at least one incident (mock and or real) Current RIRAS database includes (Total: 300 reports) 10 misadministration 277 good catches 8 anonymous good catches 35 reported incidents (CY05-14) In addition to these we have received 130 training / mock reports from RTT staff. We continue to encourage VHA radiation oncology services to report incidents and good catches in RIRAS
18 RIRAS Status Report VHA-wide Reported Incidents (CY ; Historical Data) 35 involving 42 patients Distracted RTT staff RT Equipment issues Communication issues Unintended errors Dosimetry errors Potential consequences of distracted RTT staff 1. Wrong patient setup 2. Wrong treatment site
19 Unsafe Conditions RIRAS Status Report Reporting Trends Incident Type Good Catches Actual Events* 0% 10% 20% 30% 40% 50% 60% 70% * only 3% met the criteria of VHA misadministration classification but with a low medical severity
20 50% 40% 30% 20% 10% 0% 4% RIRAS Status Report Good Catches Analysis 5/11/2014 Present (Total: 277) Event Origination Process Step 7% 40% 6% 32% 5% 1% 1% Patient Assessment 2. Imaging for Planning 3. Treatment Planning 4. Pre-treatment Verification 5. Treatment Delivery 6. On-treatment Management 7. Post -treatment Management 8. Equipment and Software Issues
21 35% 30% 25% 20% 15% 10% 5% 0% 31% Radiation physicist RIRAS Status Report Reporting Trends Staff Involved 25% Radiation therapist 19% Radiation oncologist 8% Dosimetrist
22 RIRAS Status Report Reporting Trends Common Reported Events* IT Issue Wrong MUs Prescription plan mismatch Contouring issue Inconsistent patient setup Previous RT treatment Documentation errors *Based on narrative titles
23 RIRAS Status Report Reporting Trends Number of Events Originating at Patient Assessment Process Step where discovered Post-Treatment Completion On-Treatment Quality Management Treatment Delivery Pre-Treatment Verification Treatment Planning Imaging for RT Planning
24 RIRAS Status Report Reporting Trends Number of Events Originating at Imaging for RT Planning Process Step where discovered Post-Treatment Completion On-Treatment Quality Management Treatment Delivery Pre-Treatment Verification Treatment Planning Imaging for RT Planning
25 RIRAS Status Report Reporting Trends Number of Events Originating at Treatment Planning Process Step Post-Treatment Completion 0 On-Treatment Quality Management 6 Treatment Delivery 8 Pre-Treatment Verification 53 Treatment Planning
26 RIRAS Status Report Reporting Trends Number of Events Originating at Pre-Treatment Verification Process Step Post-Treatment Completion On-Treatment Quality Management Treatment Delivery Pre-Treatment Verification
27 RIRAS Status Report Reporting Trends Number of Events Originating at Treatment Delivery Process Step Post-Treatment Completion 5 On-Treatment Quality Management 12 Treatment Delivery
28 RIRAS Status Report Reporting Trends Number of Events Originating at On-Treatment Quality Management Process Step Post-Treatment Completion 0 On-Treatment Quality Management 1 0 1
29 Organizational Management Procedural Issues Human Behavior RIRAS Status Report Good Catches Analysis 5/11/2014 Present (Analysis Total: 277) Technical 26 Causal Analysis # of Good Catches Policy & Procedures Nonexistent Inadequate Not followed Procedural Issues Distraction Loss of attention Poor documentation Human Behavior Poor judgement Lack of vigilance Technical Software operation Majority of Good catches are due to organizational management, procedural issues, and human factors. failure IT issue
30 Observations The importance of checklists to make sure all the i s are dotted and t s are crossed Inconsistent patient setup instructions/documentation Nonadherence to policies and procedures Lax time out policies Distracted RTTs at the treatment console Lack of sterile cockpit environment Poor communication between team members Inadequate RTT staffing for patient setup and delivery
31 Summary Incident reporting and learning system is a great tool for enhancing the quality and safety in radiation oncology The quality of learning is substantially improved with a thorough analysis of each reported incident Errors in radiation oncology are multifactorial in origin may be attributable to any member of the radiation oncology team.
Steven Sutlief, PhD UC San Diego February 13 th, 2015
Corrective Actions Steven Sutlief, PhD UC San Diego February 13 th, 2015 Objectives By the end of this presentation, the listener should gain A vocabulary to discussing and thinking about corrective actions,
Year in Review ro ils RO ILS
RO ILS RADIATION ONCOLOGY INCIDENT LEARNING SYSTEM Sponsored by ASTRO and AAPM Year in Review 2015 1 ro ils noun \ˈro i(-ə)ls\ Radiation Oncology Incident Learning System; a system to facilitate safer
8/2/2017. Strategies for Quality Improvement based on RO-ILS
Strategies for Quality Improvement based on RO-ILS Lakshmi Santanam Ph.D We cannot Change Human condition, but we can change the conditions under which humans work Active failures- Swat one by one Still
An Update of Radiation Oncology Quality and Safety Initiatives
An Update of Radiation Oncology Quality and Safety Initiatives Amy Heath, MS, RT(T) University of Wisconsin Hospital and Clinics Objectives Review importance of quality and safety in radiation oncology.
Incident Reporting Systems
Patient Safety in Radiation Oncology, Melbourne 4-54 5 October 2012 Incident Reporting Systems Ola Holmberg, PhD Head, Radiation Protection of Patients Unit Radiation Safety and Monitoring Section NSRW
Patient Risk (Safety) in Radiation Therapy
Patient Risk (Safety) in Radiation Therapy Michael G. Herman, Ph.D. Professor and Chair, Medical Physics Mayo Clinic Patient Safety 10/18/11 Herman # 1 Outline Radiation Therapy What Can/Did Happen? Is
Types of Errors 3/29/12. Approaches of other industries: To err is human, to forgive is divine... Human errors vs. Medical errors vs.
Medical Errors Management and Early Warning for the Medical Physicist David Hintenlang, Types of Errors Human errors vs. Medical errors vs. Medical events To err is human, to forgive is divine... Approaches
APEx Program Standards
APEx Program Standards The following standards are the basis of the APEx program. Level 1 standards are indicated in bold. Standard 1: Patient Evaluation, Care Coordination and Follow-up The radiation
Medical Errors and Medical Physics
Medical Errors and Medical Physics Michael Herman Ph.D. Peter Dunscombe, Ph.D. Bruce Thomadsen, Ph.D. Outline Introduction Are Errors A Problem? Are Medical Physicists Part of it? Quantitative Assessment
Fundamental Aspects of SBRT
What Are Fundamental Aspects? Fundamental Aspects of SBRT Fang-Fang Yin, PhD Duke University SBRT and its workflow Resources Staff Equipment Training Processes Safety Acceptance Commissioning Quality assurance
Incident Learning Systems in Radiation Therapy: Role of Culture and Potential Benefits
Incident Learning Systems in Radiation Therapy: Role of Culture and Potential Benefits Sasa Mutic Mallinckrodt Institute of Radiology Washington University St. Louis, MO Conflict of Interest Director TreatSafely.org
Clinical Implementation of Electronic Charting
Clinical Implementation of Electronic Charting Lisa Benedetti, M.S. Beaumont Health System 2013 AAPM Spring Clinical Meeting Outline I. Implementation Team II. III. IV. Process Mapping External Beam Radiation
Medical Error Prevention
Medical Error Prevention Matthew Studenski, PhD September 9, 2016 Disclosures Nothing to disclose. 1 Medical Error Prevention Definition of a medical event Look back on human error assessment Current recommendations
Error and Near-Miss Reporting in Radiotherapy
Error and Near-Miss Reporting in Radiotherapy Sasa Mutic Department of Radiation Oncology Mallinckrodt Institute of Radiology Washington University St. Louis, MO Outline Introduction Reporting infrastructure
AAPM Responds to Follow up Questions from Congress after Hearing on Radiation in Medicine
AAPM Responds to Follow up Questions from Congress after Hearing on Radiation in Medicine Table of Contents Letter from the Congressman Henry A. Waxman, Chairman of the House of Representatives Committee
Overview of TG262 on Electronic Record Keeping & Clinical Experience with ARIA. March 7, 2016 James Mechalakos Chair, TG-262
Overview of TG262 on Electronic Record Keeping & Clinical Experience with ARIA March 7, 2016 James Mechalakos Chair, TG-262 Overview TG262 overview ARIA as an information repository ARIA as a workflow
Clinical Implementation of a High Dose Rate Brachytherapy Program. Hania Al Hallaq, Ph.D. Jacqueline Esthappan, Ph.D. Joann Prisciandaro, Ph.D.
Clinical Implementation of a High Dose Rate Brachytherapy Program Hania Al Hallaq, Ph.D. Jacqueline Esthappan, Ph.D. Joann Prisciandaro, Ph.D. Learning Objectives Summarize national and international safety
Department of Radiation Oncology University of Michigan Health Systems 1
Initiative for Medical Physics Practice Guidelines Joann I. Prisciandaro, Ph.D. The Department of Radiation Oncology University of Michigan Every patient with cancer deserves to receive the best possible
YEAR IN REVIEW. ro ils RO-ILS INCIDENT LEARNING SYSTEM
RO ILS R A D I AT I O N O N C O L O G Y INCIDENT LEARNING SYSTEM Sponsored by ASTRO and AAPM 2017 YEAR IN REVIEW ro ils 1 noun \ˈro i(-ə)ls\ Radiation Oncology Incident Learning System; a system to facilitate
4. Hospital and community pharmacies
4. Hospital and community pharmacies As FIP is the international professional organisation of pharmacists, this paper emphasises the role of the pharmacist in ensuring and increasing patient safety. The
Preventing Medical Errors
Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.
AAPM TG-100 : A new paradigm for quality management in radiation therapy
AAPM TG-100 : A new paradigm for quality management in radiation therapy M. Saiful Huq, PhD, FAAPM, FInstP Professor and Director of Medical Physics University of Pittsburgh Cancer Institute and UPMC CancerCenter
Appendix G: The LFD Tool
Appendix G: The LFD Tool What is a defect? A defect is any event or situation that you don t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, like
Continuous Safety Improvement Through Incident Learning. Lulu Jordan B.S. R.T.(T) & Josh Carlson B.S.
Continuous Safety Improvement Through Incident Learning Lulu Jordan B.S. R.T.(T) & Josh Carlson B.S. No Disclosure Statement AAMD Annual Meeting Disclosure: Lulu Jordan B.S. R.T.(T) & Josh Carlson B.S.
Rasmussen s s Performance-based Actions. Errors in Radiotherapy. One Example of Error Analysis in Radiotherapy. Errors. Bruce Thomadsen Shi-Woei Lin
Errs in Radiotherapy Rasmussen s s Perfmance-based Actions Bruce Thomadsen Shi-Woei Lin University of Wisconsin - Madison Slides Bruce Thomadsen Errs l Systematic Errs: Usually one mistake tucked into
Overview of TG262 on Electronic Record Keeping & Clinical Experience with ARIA. March 7, 2016 James Mechalakos Chair, TG-262
Overview of TG262 on Electronic Record Keeping & Clinical Experience with ARIA March 7, 2016 James Mechalakos Chair, TG-262 Overview TG262 overview ARIA as an information repository ARIA as a workflow
Establishing a Radiation Safety Culture in Health Care
2 nd WHO Global Forum on Medical Devices Geneva 22-24 November 2013 Establishing a Radiation Safety Culture in Health Care Kin Yin Cheung, Ph.D. President, IOMP Hong Kong Sanatorium & Hospital, Hong Kong
Medical Errors in Radiation Therapy
Medical Errors in Radiation Therapy 2014-2015 T. Yvette Forrest Division of Emergency Preparedness and Community Support Bureau of Radiation Control Florida Department of Health 1 Reportable Medical Events
ECRI Patient Safety Organization HFACS and Healthcare
October 15, 2015 ECRI Patient Safety Organization HFACS and Healthcare Thomas W. Diller, MD, MMM VP System Chief Medical Officer CHRISTUS Health Learning Objectives Understand the human factors errors
Conflict of Interest. Patient Safety and the Training of the Medical Physicist. Training in Patient Safety
Patient Safety and the Training of the Medical Physicist Peter Dunscombe, Ph.D. Derek Brown, Ph.D. University of Calgary/ Tom Baker Cancer Centre Conflict of Interest Peter Dunscombe and Derek Brown are
Medical Physics Staffing Premise
Justification of Medical Physics Staffing for Quality Radiation Oncology Services Kenneth R Hogstrom, PhD Professor and Director Medical Physics and Health Physics Program Department of Physics and Astronomy
Application of systems and control theory-based hazard analysis to radiation oncology
Application of systems and control theory-based hazard analysis to radiation oncology Todd Pawlicki 1, Aubrey Samost 2, Derek Brown 1, Ryan Manger 1, Gwe-Ya Kim 1 and Nancy Leveson 3 1 UC San Diego, Department
Lesson 9: Medication Errors
Lesson 9: Medication Errors Transcript Title Slide (no narration) Welcome Hello. My name is Jill Morrow, Medical Director for the Office of Developmental Programs. I will be your narrator for this webcast.
Toward Minimum Practice Standards in Clinical Medical Physics:
Toward Minimum Practice Standards in Clinical Medical Physics: Response to an increasing focus on reducing medical errors and validating professional competence Per Halvorsen, MS, DABR, FACR, FAAPM October
The Practice Standards for Medical Imaging and Radiation Therapy. Radiation Therapy Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Radiation Therapy Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of this
A Systems Approach to Patient Safety at the VA
BRIGHT IDEAS A Systems Approach to Patient Safety at the VA Erika Hatva The Department of Veterans Affairs (VA) operates the largest integrated healthcare system in the United States, serving 8.76 million
SUPPLEMENTAL MATERIAL
Practical Radiation Oncology (2011) SUPPLEMENTAL MATERIAL Safety Considerations for IMRT Jean M. Moran, Ph.D.,* Melanie Dempsey, M.S., Avraham Eisbruch, M.D.,* Benedick A. Fraass, Ph.D.*, James M. Galvin,
Reducing the risk of serious medication errors in community pharmacy practice
Reducing the risk of serious medication errors in community pharmacy practice Eastern Medicaid Pharmacy Administrators Association (EMPAA) November 1, 2017 Newport, Rhode Island Michael R. Cohen, RPh,
8/2/2012. ACR-ASTRO Radiation Oncology Practice Accreditation Program. Accreditation Program Goals
ACR-ASTRO Radiation Oncology Practice Accreditation Program Tariq M Patrick Conway, MD FACR Tariq Mian, Ph.D. FACR Accreditation Program Goals Provide impartial, third party peer review Evaluate and promote
Operator Training in HDR Brachytherapy: Preventing Treatment Errors. Disclosure
Operator Training in HDR Brachytherapy: Preventing Treatment Errors Zoubir Ouhib, MS, DABR The Lynn Cancer Institute at Boca Raton Regional Hospital Boca Raton, FL Disclosure Zoubir Ouhib, MS, DABR, is
Patient Safety Culture in the Radiologic Sciences
Slide 1 Patient Safety Culture in the Radiologic Sciences Jeff Legg Virginia Commonwealth University Laura Aaron Northwestern State University of Louisiana Melanie Dempsey Virginia Commonwealth University
Mandatory Licensure for Radiologic Personnel. Christopher Jason Tien
Mandatory Licensure for Radiologic Personnel Christopher Jason Tien Licensure Permission to perform a given occupation 3 rd party examinations State hands out licenses Occupations licensed: teachers, architects,
Patient Safety Incident Report Form
Page 1 This form is not meant to be a substitute to the health region s incident reporting. The purpose of this form is to assist with the identification and management of adverse events and near misses;
Objectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014
ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst,
Susan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center
Engaging the team: Steps to Reduce Complications Susan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center Safety
Reporting an Incident
Why we have a procedure? Standard Operating Procedure 1 (SOP 1) Reporting an Incident The Trust acknowledges that, as a large and complex provider of clinical and nonclinical services, things sometimes
The Practice Standards for Medical Imaging and Radiation Therapy. Medical Dosimetry Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Medical Dosimetry Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of this
Shifting from Blame-&-Shame to a Just-and-Safe Culture
Shifting from Blame-&-Shame to a Just-and-Safe Culture Barb Sproll Medication Safety Pharmacist Winnipeg Regional Health Authority 29 May 2018 Conflict of Interest I have no conflicts to disclose. Objectives:
QAPI Making An Improvement
Preparing for the Future QAPI Making An Improvement Charlene Ross, MSN, MBA, RN Objectives Describe how to use lessons learned from implementing the comfortable dying measure to improve your care Use the
Nexus of Patient Safety and Worker Safety
Nexus of Patient Safety and Worker Safety Jeffrey Brady, MD, MPH & James Battles, PhD Agency for Healthcare Research and Quality October 25, 2012 Diagnosing the Safety Problem is One Challenge The fundamental
http://www.bls.gov/oco/ocos299.htm Radiation Therapists Nature of the Work Training, Other Qualifications, and Advancement Employment Job Outlook Projections Data Earnings OES Data Related Occupations
The Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS
The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS 6051 Clinical Errors 9083 Laboratory Errors 15134 Errors over 6 years I don t want
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University
Medical Event Reporting
Medical Event Reporting Scott Dube, MS DABR Morton Plant Hospital Clearwater, FL New Voluntary Reporting System For some, reporting is mandatory Radioactive materials are regulated by either the NRC or
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN 2014 1 PATIENT SAFETY PLAN 2014 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Medical Center (UMMC) is to
Leadership and Culture: Building Highly Reliable Systems of Care
Learning Objectives Leadership and Culture: Building Highly Reliable Systems of Care Michael Batchelor, CEO Baptist Easley Hospital Easley, South Carolina Discuss recent developments in health systems
10/4/2012. Disclosure. Leading a Meaningful Event Investigation. Just Culture definition. Objectives. What we all have in common
Leading a Meaningful Event Investigation Natasha Nicol, Pharm D, FASHP Director, Medication Safety Cardinal Health Disclosure I do not have a vested interest in or affiliation with any corporate organization
M. Coffey, M. Leech and P. Poortmans on behalf of ESTRO and the RTT committee
Benchmarking Radiation therapist (RTT) Education M. Coffey, M. Leech and P. Poortmans on behalf of ESTRO and the RTT committee Introduction A benchmark is a point of reference to enable comparison with
Introduction. Human Factors Engineering and Safety in Radiation Oncology
Human Factors Engineering and Safety in Radiation Oncology Introduction Jim Schewe Philips Radiation Oncology Systems North Central Chapter, AAPM Fall 2015 1 Overview Human Factors in Software: General
RADIATION ONCOLOGY RESIDENCY SUPERVISION POLICY
RADIATION ONCOLOGY RESIDENCY SUPERVISION POLICY This policy is intended to guide the activities of radiation oncology residents in insuring that patient care activities in which residents participate are
Statewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS
Statewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS What is safety culture? The safety culture of an organization is the product of individual and group values, attitudes, perceptions,
QUARTERLY REPORT PATIENT SAFETY WORK PRODUCT Q APRIL 1, 2017 JUNE 30, 2017
QUARTERLY REPORT PATIENT SAFETY WORK PRODUCT Q2 2017 APRIL 1, 2017 JUNE 30, 2017 CLARITY PSO, a Division of Clarity Group, Inc. 8725 West Higgins Road Suite 810 Chicago, IL 60631 T: 773.864.8280 F: 773.864.8281
Code of Practice for Radiation Therapy. Draft for consultation
Code of Practice for Radiation Therapy Draft for consultation Released 2017 health.govt.nz Citation: Ministry of Health. 2017. Code of Practice for Radiation Therapy: Draft for consultation. Wellington:
Hands-on SBRT Workshop
Hands-on SBRT Workshop October 14-16, 2016 in partnership with ~ AAPM endorses the educational component of this program. ~ It does not however, endorse any product used or referred to in the program.
Medication Safety in LTC. Objectives. About ISMP Canada
Medication Safety in LTC Part II -Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety Lynn Riley, RN ISMP Canada Thursday, October 20, 2011 Objectives At the end of
MARYLAND RADIATION CONTROL ADVISORY BOARD MINUTES December 4, 2017
MARYLAND RADIATION CONTROL ADVISORY BOARD MINUTES December 4, 2017 Maryland Department of the Environment Air and Radiation Administration Radiological Health Program MEMBERS PRESENT Richard Hudes, M.D.
How Should Policy Reflect a Culture of Safety?
How Should Policy Reflect a Culture of Safety? BETA Healthcare Group BETA HEART Domain I: Culture of Safety All Rights Reserved 2016 Table of Contents How Should Policy Reflect a Culture of Safety?...
On the CUSP: Stop BSI
On the CUSP: Stop BSI Learning From Defects December 6, 2011 Comprehensive Unit-based Safety Program (CUSP) 1. Educate staff on science of safety (www.safercare.net) 2. Identify defects 3. Assign executive
Medical Physics and the Challenges Faced in Africa
Medical Physics and the Challenges Faced in Africa by Rebecca Nakatudde 1. Assistant lecturer, Department of Radiology, College of Health Sciences, School of Medicine, Makerere University. 2. Vice president,
Tools for risk assessment in radiation therapy
Tools for risk assessment in radiation therapy ICRP Symposium on the International System of Radiological Protection October 24-26, 2011 Bethesda, MD, USA Dr. Pedro Ortiz López ICRP Committee 3 Task
The ASRT is seeking public comment on proposed revisions to the Practice Standards for Medical Imaging and Radiation Therapy titled Medical Dosimetry.
The ASRT is seeking public comment on proposed revisions to the Practice Standards for Medical Imaging and Radiation Therapy titled Medical Dosimetry. To submit comments please access the public comment
Louisville, Kentucky! MEDICAL PHYSICS WORKFORCE ASSESSMENT 2012 AAPM SPRING CLINICAL MEETING. List of Topics. Complexity, Safety and Quality Assurance
Louisville, Kentucky! Michael D. Mills MEDICAL PHYSICS WORKFORCE ASSESSMENT 2012 AAPM SPRING CLINICAL MEETING List of Topics Complexity, Safety and Quality Assurance Where is the QA Knowledge? Staffing
Role of the medical physicist in the safe and appropriate use of radiation medical devices
Role of the medical physicist in the safe and appropriate use of radiation medical devices Second Global Forum on Medical Devices Geneva, 22-24 November 2013 Habib Zaidi 1,2 1 Geneva University Hospital,
The Alphabet Soup of Regulatory Compliance: Being Prepared for Inspections. Objectives. Inspections are often unannounced, so DOCUMENTATION
The Alphabet Soup of Regulatory Compliance: Being Prepared for Inspections Linda Kroger, MS UC Davis Health System Objectives Recognize the various regulatory bodies and organizations with oversight or
APEx ACCREDITATION PROCEDURES. April 2017 TARGETING CANCER CARE. ASTRO APEx ACCREDITATION PROCEDURES
APEx ACCREDITATION PROCEDURES TARGETING CANCER CARE April 2017 ASTRO APEx ACCREDITATION PROCEDURES 2017 1 TABLE OF CONTENTS THE APEx PROGRAM 3 THE PROCESS OF APPLYING FOR APEx ACCREDITATION 5 FACILITY
IHI Open School Advanced Case Study October 14, 2010 Clemson University
IHI Open School Advanced Case Study October 14, 2010 Clemson University Catherine Simmons 1, Drew Sargent 1, and Kate Wright 1 Public Health Science Hallie Bagnal 2 and Megan Hohenberger 2 Biological Science
Accreditation of Education and Professional Standards of Medical Physicists
ID 142 Accreditation of Education and Professional Standards of Medical Physicists Kin Yin Cheung & Slavik Tabakov International Organization for Medical Physics IAEA International Conference on Advances
Incident Reporting and Learning
Section 3 Incident Reporting and Learning Contents Guidelines to defining and managing all radiation incidents Definition of a Patient Radiation Incident Definition of a Near Miss Patient Radiation Incident
February New Zealand Health and Disability Services National Reportable Events Policy 2012
February 2012 New Zealand Health and Disability Services National Reportable Events Policy 2012 Table of Contents 1. Purpose 2. Treaty of Waitangi 3. Background 4. Scope 5. Policy 6. Review and Evaluation
THE ROLE OF HEALTH MANAGERS IN PROMOTING MEDICAL PHYSICISTS IN AFRICA
THE ROLE OF HEALTH MANAGERS IN PROMOTING MEDICAL PHYSICISTS IN AFRICA Nakatudde, R. 1,2,3, Ige, T. 2, Ibn Seddik, A. 2, El-Shahat, K. 2 1. Assistant lecturer, Department of Radiology and Radiotherapy,
TIME OUT! A Patient Safety Strategy. Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service
TIME OUT! A Patient Safety Strategy Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service Disclosures The opinions expressed in this presentation are those of the authors and
BAY-ARENAC BEHAVIORAL HEALTH AUTHORITY POLICIES AND PROCEDURES MANUAL
Page: 1 of 14 Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) that all adverse events, such as unusual events (including risk), critical incidents (including all deaths) and sentinel
ACR Radiation Oncology Practice Accreditation Program (ROPA)
ACR Radiation Oncology Practice Accreditation Program (ROPA) ACR Radiation Oncology Practice Accreditation Program Everything You Need to Know Brian T. Monzon MBA RT(R)(T) Program Manager Quality and Safety
Root Cause Analysis A Necessary Evil? Dr Joseph Lui HA Convention 8 th May 2012
Root Cause Analysis A Necessary Evil? Dr Joseph Lui HA Convention 8 th May 2012 Root Cause Analysis (RCA) The use of RCA as an organization learning tool first deployed by Veteran Affairs Hospitals in
NUCLEAR SAFETY PROGRAM
Nuclear Safety Program Page 1 of 12 NUCLEAR SAFETY PROGRAM 1.0 Objective The objective of this performance assessment is to evaluate the effectiveness of the laboratory's nuclear safety program as implemented
EMS Peer Review: How We Do It, Protect It and Drive Innovation
EMS Peer Review: How We Do It, Protect It and Drive Innovation Title: John Enter Romeo, title SCCAD of your presentation here Presenter: Lee Varner, Enter Center your for Patient name Safety here SCCAD
ADMINISTRATIVE POLICY & PROCEDURE PATIENT SAFETY PLAN
PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure
Enhancing Patient Quality and Safety with Compliance
Enhancing Patient Quality and Safety with Compliance April 23, 2013 John Kalb, JD, CCEP, CHPC Operational Excellence Executive/ Compliance Officer Kootenai Health Content A successful compliance program
Refer to Appendix A for definitions of the terminology used throughout this policy.
Category: BOARD POLICY ADMINISTRATIVE PARAMETERS Title: Stop the Line : Authority to Intervene to Ensure Patient Safety Approved by: PHSA Board of Directors Reference Number: AS 130 Last Approved: June
HIPAA Training
2011-2012 HIPAA Training New Hire Orientation and General Training 1 This training is to ensure all Health Management workforce members (associates, contracted individuals, volunteers and students) understand
Sandra Trotter, MBA, MPHA, CPHQ PATIENT SAFETY PROGRAM LUCILE PACKARD CHILDREN S HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER
Sandra Trotter, MBA, MPHA, CPHQ PATIENT SAFETY PROGRAM LUCILE PACKARD CHILDREN S HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER LUCILE PACKARD CHILDRENS HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER PALO ALTO,
Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM
Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Objectives Know TJC 2016 National Patient Safety Goals Discuss human factors on patient safety What is your role in patient safety?
1. Have you or a member of your family had first-hand experience of an adverse event or experienced harm in a healthcare setting in your country?
Patient Safety p.1 Submission: 163 Stakeholder group Other other, please specify Hospital Country Germany Role in organisation management Number of employees 250 - Your organisation's geographical area
Using the Just Culture Method. Stacey Thomas, BSN, RNC Risk Analyst
Using the Just Culture Method Stacey Thomas, BSN, RNC Risk Analyst Just Culture A system of Shared Accountability Everyone in the organization is responsible for maintaining a safe and reliable system
Building and Sustaining a Culture of Safety
Building and Sustaining a Culture of Safety Ann Shimek, MSN, RN, CASC Senior Vice President, Clinical Operations United Surgical Partners International 028 Session Objectives q Describe organizational
Quality and Safety Considerations You Haven t Thought About
Quality and Safety Considerations You Haven t Thought About Learning Objectives Understand safety from a systems view. Understand & give examples of safety barriers. Be able to take actions to improve
Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD
Presented by: Suchita Pancholi, MD Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD I. Introductions II. III. IV. Marshmallow Challenge Why Teach Patient Safety? Barriers to Teaching Patient Safety V.
University of Washington School of Nursing - Continuing Nursing Education 1
A Team Approach to Patient Safety: TeamSTEPPS University of Washington Medical Center Kat Comstock, Associate Director Center for Clinical Excellence/Patient Safety Officer Describe TEAMSTEPPS using the
Residency Program in Medical Physics. Vassar Brothers Medical Center. Self-Study. May 26, Program Director. Serguei Kriminski, PhD, DABR
Residency Program in Medical Physics Vassar Brothers Medical Center Self-Study May 26, 2016 Program Director Serguei Kriminski, PhD, DABR 45 Reade Place Poughkeepsie, NY 12601 skriminski@health-quest.org
EDUCATIONAL REPORT SPONSORED BY Imprivata. The Value of Precise Patient Identification
The Value of Precise Patient Identification Many hospitals and health systems rely on manual processes to identify patients at registration, as well as modalities like armbands and barcodes to identify