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.
Promoting a community of continuous learning from incidents
In 2018 CPQR and CIHI established the NSIR-RT Advisory Committee to oversee the operation and evolution of NSIR-RT to assure it meets the current and future needs of the radiation treatment community. The committee also reviews radiation treatment incident data submitted to NSIR-RT, informs the radiation treatment community of important patterns and trends, and makes recommendations to minimize or mitigate risk.
The NSIR-RT Advisory Committee shares its findings through quarterly NSIR-RT Bulletins. Access current and past issues of NSIR-RT Bulletin, sign up to receive quarterly email updates so you don’t miss the latest developments!
Radiation Treatment Incident Investigation and Learning Course
In 2017 CPQR launched a virtual faculty-directed course that taught participants 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. Based on the successful interactive course, CPQR launched an independent online course in 2018.
Access the free online course here
Supporting National and International Alignment
The minimum dataset (MDS) used by NSIR-RT is copyrighted by CIHI and developed in partnership with the Canadian radiation treatment community. A core tenet of CPQR is to encourage pan-Canadian and international alignment so we can work together to learn and improve the quality and safety of radiation treatment delivery. With permission from CIHI, CPQR is pleased to make the MDS available online for the first time. CPQR encourages programs to review their local reporting system against this dataset and update their taxonomy where appropriate. (Note: Please remember that this document is being made available to support alignment and should not be reproduced or used for commercial purposes as detailed in the document copyright.)
What will be done next
The success of NSIR-RT depends on its utility within local radiation treatment programs. CPQR will work with the Canadian Association of Provincial Cancer Agencies (CAPCA) to promote and expand the utilization of NSIR-RT and support continuous quality improvement. Regular reporting of submitted-incident trends will continue to be shared with the broader community through the quarterly NSIR-RT Bulletin. The development of a tool for reporting metrics to local radiation treatment programs is our hope for the future, so stay tuned!