National System for Incident Reporting – Radiation Treatment

A National System for Reporting Radiation Treatment Incidents

Learning from our mistakes


A key element of radiation treatment quality assurance is learning from potential and actual incidents that occur during treatment planning and delivery. While most radiation treatment programs in Canada have internal incident monitoring systems that link to broader hospital risk management systems, many do not capture the granularity of detail required to inform quality improvement.

CPQR has partnered with the Canadian Institute for Health Information (CIHI) on the development of a pan-Canadian system for incident reporting of radiation treatment incidents.  Called the National System of Incident Reporting – Radiation Treatment (NSIR-RT), the system builds on the NSIR database currently used to track medication incidents across the country and is being used as a tool to report, track and analyze incidents from their local program, and anonymously from other Canadian centres.

Beta testing of NSIR-RT was conducted at 22 centres in 5 provinces for a 12-month period ending September 2016.  A sixth province provided further pilot data through comprehensive testing of the NSIR-RT data set at all provincial centres.  In October 2016, CPQR and CIHI undertook a comprehensive review of pilot data, and used that data, coupled with systematic user surveying, to guide system revisions.  It is expected that those revisions will be incorporated into the NSIR-RT system in spring 2017.

Community Engagement

The success of NSIR-RT depends on its utility within local radiation treatment programs.  During beta testing, CPQR and CIHI facilitated local awareness and utilization of NSIR-RT through regular education sessions and program update communique.  Check out our latest NSIR-RT Update, and sign up to receive email updates so you don’t miss the latest developments!

CPQR is excited to be offering the second session of the incident learning course in partnership with CIHI and the Accelerated Education Program (AEP) at the University Health Network.  This web-based 7-week course will teach attendees how to effectively investigate local incidents using the Canadian Patient Safety Institute (CPSI) guidelines, identify trends through local and pan-Canadian incident analysis and inform programmatic change with the aim of improving overall patient care and outcomes  Check out the course outline for more information.

Course Start: April 2018.

Where are we going next?

Building on the success of the NSIR-RT pilot, CPQR will investigate the feasibility of facilitating patients and/or families to report radiation treatment quality of care and/or safety events directly to NSIR-RT, as a way to identify gaps and deviations in the radiation delivery process and to benefit patient care across the country.

This work will include:

  • A scan of the international environmental activity as it pertains to patient reported incidents
  • Meeting with international partners and discussing incidents and experiences of patient reported radiation treatment
  • A survey of both patients and end users (provincial cancer agencies, radiation oncologists and therapists etc.) as well as other key stakeholders regarding resulting attitudes towards patient reported radiation treatment quality of care & safety, inclusive of patient value and willingness of system use by patients and their families.