Why declare events? What to draw from experience feedback?

Abstract

Abstract Issue In France, the reporting of significant radiation events for nuclear activities is a mandatory system since July 2007 following the accident of oncology in Epinal. Later, the directive 2013/59/EURATOM states that Members of the European Union shall ensure that a system of experience feedback is in place for the dissemination of lessons. In France, it was implemented in 2011 through the publication of a newsletter, “Patient safety: Paving the way for progress” on radiotherapy, it is now extended to medical imaging. Until 2015 the number of reported events was stable but steadily decreasing in radiotherapy since 2016. Lack of time to report, lack of awareness and training of doctors, fear of consequences in terms of communication on the establishment that reports and in terms of control by the ASN following the report may explain the decrease. Educational actions need to be lead to reaffirm the objectives of reporting and reinforce the interest of experience feedback. The French Nuclear Safety Authority decide to focus a newsletter on international reporting systems and Experience feedback based on the reflections of a French institutional working group. Results According to professionals it is sometimes difficult to report an event with impact on patients, easier to work on near miss and even easier to work on events happening elsewhere. Reporting an incident is thus a collective action. The experience feedback process allows learning in order to improve practices in the future and address three aspects: Benchmarking, Prospective risk analysis for the techniques/devices which have never been used in a centre, Analysis of concrete cases during feedback experience meetings. The limit of the current systems is the difficulty in finding precise information due to shortcomings in its structure. A simplified system is needed. Lessons Reporting events on websites highlight new events and enable the solutions implemented elsewhere to be disseminated in our own networks. Key messages Reporting adverse events or near miss has a collective impact. Experience feedback allows dissemination of lessons and prevents incidents.