Poster — Thur Eve — 56: A Comprehensive System for Classifying, Recording and Analyzing Incidents, Accidents, and Other Events in a Radiotherapy Practice

Introduction: An event reporting program was created in a large radiotherapy facility. The aim of the program was develop a classification system for radiation events to improve quality in patient treatment. An event was defined as any action which caused or could have caused the incorrect treatment of the patient or led to the delay of a patient's treatment. Methods and Materials: An event reporting committee comprising of senior members of staff was formed and an anonymous event reporting form and mechanism were created. The data was analyzed and educational feedback were given to the entire staff. Results: The project is ongoing at our clinic, but the data was collected over a 3‐year period starting January 1, 2007. Events are initially evaluated immediately after occurrence, and every few weeks the committee assembles and categorizes the events reports. A total of 971 events were recorded. After an initial increase from 335 events in 2007, to 437 in 2008, 2009 registered only 199 errors. The total event rate per fraction is less than 1% (0.00719), but the overall event rate per patient is about 11%. Also we note that the accident rate (events which have dosimetric consequences for the patient) is relatively low with only 39 events for the 3 year period, about 1 event per month. We also note that near misses account for about 15% of all events. The largest number events (∼15%) occur during treatment delivery, this is expected as this is the most frequent activity.