Lessons Learned From the VA Radiotherapy Incident Reporting and Analysis System (RIRAS)

Abstract

The intranet Web-based RIRAS was developed and deployed in the Veterans Health Administration (VHA) System to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences at its 39 radiation oncology practices nationwide. 286 reports were electronically submitted to the RIRAS between 5/11/2014 and 1/02/2017. Each reported event included information on the incident chronology, general information specific to the treatment modality, site and intent and free text narrative. All reports were carefully analyzed by a radiation oncology subject matter expert (SME) and assigned to one of the eight discrete radiation oncology process steps. Steps relate to where the event was discovered and/or occurred. As part of the analysis, error type, medical and dosimetric severity, interventions and potential causes were recorded for each report. Patient safety work products (PSWP) created for these reports listed corrective, preventive and learning actions. For learning purposes, the anonymized version of each PSWP is publicly available on the RIRAS website, which enhances the safety culture. We completed causal analysis and developed corrective action plans for 100% of the reported incidents. Out of a total of 286 reports, 35% were actual events of which 3% met the criteria of VHA misadministration classification but with a low medical severity. 61% were good catches/ near misses, 4% were unsafe conditions. 32% of the reported events occurred in the treatment planning phase, 28% in the treatment delivery phase and 7% in the imaging for treatment verification phase. 31% of the events were discovered by the radiation physicist, 25% by the radiation therapist and 19% by the attending radiation oncologist. 32% of the events were related to organizational management issues like non-existent or inadequate policy and procedures. 31% were related to procedural issues such as distractions / loss of attention and poor documentation. 24% were human behavior related to poor judgement and lack of vigilance. 9% were based on technical issues such as lack of IT / biomedical attention. 36 reports were due to documentation errors, 11 based on previous RT treatment not taken into account for retreatment and 12 due to inconsistent patient setup instructions. Based on the analyses of reported incidents, we were able to make individualized recommendations for radiotherapy process improvement to enhance patient safety at each reporting facility. While RIRAS utilization is a marker of a positive safety culture within VHA, it is important to have a concrete plan for following up, learning and documenting process improvements from the reported events. We found that the ability to learn is significantly enhanced when the reporter is self-identified and there is an ability to request additional information on the event.