Patient incidents Flashcards
What does the External Reporting guidance: CQC Jan 2017 include?
Guidance on investigating
Guidance on when to notify
List of incident types to notify
Includes RT incidents
What incidents should be reported to the HSE?
If an exposure fails to stop and MGTI is reached
What do the Medical and Dental guidance notes contain?
Good practice on all aspects of ionising radiation protection
Chapters on RT and brachytherapy
What does towards safer radiotherapy contain?
Classification system for non-equipment errors
Allows national sharing of similar incidents
Allows national trends to be seen
Identifies most risky parts of RT process
When may reportable incidents not be clinically significant?
It is correctable by the end of treatment but 20% high for one fraction
Multiple imaging repeats due to procedural error
Should underdoses be reported under IRMER?
Technically no but it is good clinical practice
Are mistakes found during plan checks near misses?
No
What does the quality of the data the TSR presents dependent on?
How committed hospitals are to reporting ‘non-reportable’ incidents
What is the most common type of incident reported?
Treatment unit process
In an incident what are the first things that need to be established?
Description of what happened
has the patient been over-dosed?
How many fractions?
Is it correctable?
Is it an equipment fault? Should it be taken out of use?
What should happen to the patient? Stop? Continue as planned? Continue with modified dose?
Who should be notified of an incident locally?
Patient Clinical director RT head of service Oncologist Head of RT physics Lead radiographer Directorate manager Physics service lead RPA (if appropriate) Risk department Hospital incident database Trust exec
Who reports an incident?
Risk office
What should make up the investigation?
Collect recollections of what happened, who was involved, who saw it?
Collect electronic logs from the computer of user actions, treatment delivery logs, equipment self monitoring logs
Why is it important to find the root cause of an incident?
A trigger may have caused long standing problems to become an incident
If procedures aren’t followed then find out why? Is it difficult to understand, is it out of date, is it ever followed?
What needs to be considered when deciding how to end the course of treatment?
Tolerance of delivery equipment
Patient condition
Trust policies
legislation and national reporting requirements
