The accurate and unambiguous classification and coding of near-misses, incidents and errors is essential to improving patient safety in radiotherapy. Here, professional officer of the SCoR Maria Murray, reports on a national event aimed at demystifying the new classification and coding system as set out in the 2008 publication Towards Safer Radiotherapy.
On 4 June 2009, more than 90 delegates – with representation from radiographers, radiotherapy service managers, radiotherapy physicists and quality managers – gathered in Birmingham to attend a workshop entitled Radiotherapy Errors & Near Misses: National Voluntary Reporting.
The aim of the event was to introduce the new reporting system, and provide training in classifying and coding radiotherapy errors (RTEs) and near-misses, as described in Towards Safer Radiotherapy (TSR).
A draft guidance document, which has been piloted by six RT departments, was launched to the workshop for comment and feedback before it is shared with the wider radiotherapy community. I knew about the National Patient Safety Agency (NPSA) working group Patient Safety in Radiotherapy following the publication of TSR, and I was very keen to participate in the workshop.
The morning session consisted of presentations; an overview was given of current reporting of RT incidents and the new voluntary system outlined; two of the pilot sites (Mount Vernon and Colchester) gave their experiences on working with the guidance document, with detail given on the electronic incident reporting process at Colchester; and an overview of the Reporting & Learning System (RLS) was given by the NPSA.
The afternoon workshops consisted of categorising dummy RT error/near-miss scenarios information using the classification and coding system in TSR. This requires the use of the RTE classification grid, followed by coding using the RT pathway. This raised a great deal of debate, as well as plenty of questions regarding, in particular, when to use level 2 or level 3 categories.
The workshops clarified that it is important to define what ‘reportable’ means – both for the mandatory reporting and local reporting for governance reasons. Updated guidance on reporting incidents under IR(ME)R (ie ‘much greater than intended’) was sought by the delegates, as well as the need to include the mandatory reporting of ‘under-doses’ within the regulations. It was agreed that further guidance on what constitutes a reportable error would be beneficial and the Health Protection Agency (HPA) agreed to raise this with the appropriate inspectorates.
The idea of the new reporting system is to facilitate learning from errors and near-misses among the RT community, and it will commence with an RTE report in the local RT department submitted to the local risk management department for upload to the RLS. NPSA then extracts RTEs from the RLS for transfer to HPA for analysis, finishing with a report from HPA to be placed on the NPSA website for all to review. The HPA analysis and potential learning within the RT community will obviously be pivotal to safer practice.
The new reporting system does rely on the local risk management department to upload a greater volume of RTE reports to the RLS. Therefore, details need to be very specific in order to ensure information is not lost in translation; and the system includes the use of a ‘trigger code’ in reports to facilitate this.
It became obvious that a thorough understanding of the RT pathway is pivotal in allocating classifications and codes. It is important to identify the ‘initiating event’ as sometimes not obvious, especially in a complex case. Some delegates suggested that there should be more codes included, and that ‘training’ in the pathway coding is an important issue.
It became apparent during the event that when classifying and coding RTEs/near-misses the following points are important for ‘good reporting’:
• A thorough knowledge of local policies and procedures and the full facts surrounding the RTE are required to enable accurate classification and coding;
• Assign a code for the primary point in the
RT pathway where the first error occurred
• Assign additional codes to subsequent errors using the pathway;
• Objectivity is required.
To find out more email Geri Briggs or Una O’Doherty.
• NPSA host a National Reporting & Learning Service (NRLS) which includes a data management system (known as Reporting & Learning System (RLS) into which Patient Safety Incidents (PSI) are reported anonymously (using vendor systems such as DATIX). A paper copy of the draft practical guidance TSR Classification & Coding and the National Voluntary Reporting Systems was handed out at the event with the opportunity for delegates to feed back comments. The final guidance will be launched on the NPSA website shortly, but it must be stressed that this guidance does not replace the existing mandatory responsibility to report under the Regulations: IRR 99 and IR(ME)R 2000/06.
• The Towards Safer Radiotherapy self assessment toolkit is now complete and available for use online. Click here.
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