QUALITY AND RISK MANAGEMENT
Part 1 - Risk Managament & Patient Safety
Bruges•Belgium
15-18 November 2012
Early rate deadline: 15 August 2012
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Course Director
Pierre Scalliet, Radiation Oncology, UCL Cliniques Universitaires St.Luc, Brussels (BE)
Teachers
Mary Coffey, Associate Professor , School of Medicine, Trinity College Dublin (IE)
Peter Dunscombe, Medical Physicist, Tom Baker Cancer Centre, Calgary, Alberta (CA)
Tommy Knoos, Medical Physicist, Lund University Hospital, Lund (SE)
Petra Rejinders-Thyssen, Manager Patient Safety, Maastro Clinic, Maastricht (NL)
Eric Lartigau, Radiation Oncologist, Centre Oscar Lambret, Lille (FR)
Course aim
This course is part of a two years cycle on quality management in radiotherapy, consisting of two complementary modules:
1. Part I: Risk management & patient safety
As described below, to be held from 15-18 November 2012
2. Part II: Quality improvement & indicators
This second part of the cycle will be organized in 2013
Industrial and medical activities expose operators and/or customers and/or the general population to the risk of accidents that cause corporal or environmental damage (or both). Harm to operators is very uncommon in radiotherapy, but harm to patients happened in the past and got considerable press coverage in many European countries. These widely publicised accidents have focused the attention of both the radiotherapy house and the regulatory authorities on the appropriate preventive actions that could be taken to avoid their repetition.
Fortunately, accidents that actually result in harm to patients are rare. Conversely, small irregularities in the radiotherapy process are very frequent, many hundred a year in every department. A key to the understanding of the genesis of accidents is the fact that these small irregularities (called precursors), as benign as they seem to be when considered isolated, can mesh together to result in a fully developed accident. An accident is not the result of very uncommon irregularities; it is the coincidence of very common irregularities that unfortunately concur at a given point in time.
Accidents are rare and, above all, difficult to prevent. However, precursors are easy to identify. Actively working on these precursors (registration, description, classification), and working on improvements in the radiotherapy process (prevention) is an efficient way to greatly decrease the risk of accidents. In some European countries it is even mandatory to record and report on precursors. In addition, preventive analysis can be done of any radiotherapy process, trying to identify a priori critical elements that need specific monitoring or quality controls (failure mode analysis).
Target Group
The course is aimed at radiation oncologists, medical physicists, radiation technologists and any other health professionals interested in risk management and patient safety.
Educational Programme
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What is risk? Psychology of making mistakes;
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Ethics for radiation medicine professionals;
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Example of the genesis of an accident;
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ROSIS the precursor in Europe. Frequency of incidents (who reports and what type of incidents are reported);
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Taxonomy and classification, distinction between incident and accident;
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Analysis and return on experience (root cause analysis);
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Failure mode and effect analysis;
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Communication to patient;
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Communication to the media;
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Specific training of staff;
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National systems for reporting to regulatory authorities;
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Comprehensive quality management in radiotherapy.
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Practical exercises (hands on)
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Performance indicators - STC new course!
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