P290] Radiotherapy risk analysis from incidence reports at a national level

Abstract

Purpose In order to share data on patient risk during radiotherapy (RT) on a national level and to stimulate a learning potential between the RT-centers, a national special group of interest in RT (RT-SIG) under the national society for medical physics was formed in 2016. Since then RT-SIG has collected and analyzed patient risk data from six centers. RT-SIG is stimulating the centers to analyze and categorize data in an inter-center consistent way facilitating sharing of data and making common reports and recommendations on patient RT safety improvements. Methods Adverse and near miss incidence reports in RT are collected and analyzed locally at each center. Events are categorized by two different systems, 1 Patient Consequence Coding (PCC) according to the kind of consequence experienced by the patient and 2 RT Pathway Coding (RPC) according to the RT process at which the incident originated. Consensus surveys are performed twice a year in order to standardize local data analysis by the local center Risk Analysis Team. During 2017 local data were collected, and incidence patterns on a national level as well as on local RT-centers were analyzed. Results Data of the consensus surveys are presented. Preliminary results on patient data analysis from 2016 have shown a big difference in the reporting activity between the participating centers whereas the risk patterns are quite similar. The majority of the incidents are found to occur in the planning steps of the RT course, giving risk of systematic errors through the entire course of RT. New national data for 2017 including anonymized inter-center comparison results will be presented. Data indicates consistent data analysis and similar risk profiles between the six participating RT-Centers. Conclusion Due to training of the risk analysis teams at different RT centers, it is possible to use a common data categorizing system making inter-center analysis and comparisons feasible. Data from six centers show a different reporting frequency. However, a similar risk profile indicates that pooled national data have the potential of developing a system for early warnings of RT risks between the centers and for common national recommendations on patient safety.