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 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.
Organization in Charge
CAPCA and CPQR are pleased to announce that effective October 1, 2021, CPQR will become a standing committee within CAPCA. This is an important step to sustaining radiation treatment quality improvement advances made over the last 10 years, improving clinical outcomes through radiation treatment innovation and strengthening system performance.
CAPCA’s Canadian Partnership for Quality Radiotherapy Committee (CPQR Committee) will serve as a pan-Canadian radiation treatment network hub and provide direct stewardship of national radiation treatment incident reporting.
The CPQR Committee will continue to work with CIHI 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. Sign up for updates.
Since 2016 CPQR has issued a quarterly NSIR-RT Bulletin which features case studies highlighting trends found in submitted incident data and provides valuable learning opportunities for the Canadian radiation treatment community. Click here to access the NSIR-RT Bulletin archive.
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. With permission from CIHI, CPQR made the MDS available online. Programs are encouraged 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.)
Global Patient Safety Alerts
In 2021, CPQR was invited to participate in the Global Patient Safety Alerts. Global Patient Safety Alerts was launched 2011 by the Canadian Patient Safety Institute (CPSI) with the support of the World Health Organization (WHO) and is a searchable web-based resource containing patient safety alerts, advisories and recommendations for healthcare providers and organizations. CPQR does not monitor incident submissions for the purpose of identifying specific incidents warranting dissemination but may respond to requests to disseminate safety advisories from provincial cancer agency leadership, where there may be action required by radiation treatment programs or the broader cancer community.