Incident Investigation Course

Introduction

Both within Canada, and around the world, advances are being made in how radiation treatment programs identify, classify and report incidents and then use the collected data to reduce incident propagation and improve patient and staff safety.  This independent learning program will teach 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.

Watch the course Introduction here

Session 1a & b

Course Overview

Faculty will describe the importance of incident investigation, learning and reporting; radiation treatment programmatic response to an incident; and types of radiation treatment patient safety events. They will provide an introduction to methods for analysing incidents including the CPSI incident reporting framework and the London protocol for incident investigation; an overview of incident reporting requirements in Canada and internationally; and an introduction to NSIR-RT system.

Watch Session 1a here

Watch Session 1b here

Session 2

Concise Incident analysis

Participants will have a more in-depth look at the CPSI concise incident investigation guidelines for no or low harm events drawing on investigation and analysis examples grounded in real-world patient safety events.

Watch Session 2 here

Session 3

Comprehensive incident analysis

Using more real-life examples, participants will explore the CPSI comprehensive incident investigation guidelines for complicated or complex events or those associated with severe harm.

Watch Session 3 here

Session 4

NSIR-RT

Participants will learn the history, development and scope of NSIR-RT- its key features, organization and data structure, the NSIR-RT minimum data standard, and NSIR-RT analytical tools.

Watch Session 4 here

Session 5

Incident Classification using NSIR-RT (Round 1)

Participants will practice using NSIR-RT to classify radiation treatment patient safety events commonly encountered in routine clinical practice provided by faculty and by participants.

Watch Session 5 here

Session 6

Incident Classification using NSIR-RT (Round 2)

Participants will further refine their radiation treatment incident classification skills using NSIR-RT with challenging, frequently misclassified patient safety events both provided by faculty and by participants.

Watch Session 6 here

Session 7

Moving Ahead

Faculty will highlight the key opportunities and challenges for implementing incident learning processes at the local, regional and national level – including strategies and tools to facilitate success.  Participants will learn about pan-Canadian, grass roots initiatives aimed at building capacity and supporting the uptake of incident investigation, reporting and learning.

Watch Session 7 here