Centralised Radiation Oncology Incident Reporting

Quality Corner

Inadvertent administration of radiation doses other than those intended occurs in all radiation therapy settings. The occurrence and consequences can be minimised by systematic reporting and analysis of radiation incidents and so-called near misses, with feedback to radiation therapy professionals. Legislation and professional standards, such as the Radiation Oncology Practice Standards produced by the Radiation Oncology Alliance, require radiation therapy providers to have systems for this.

Although reporting of major incidents to the Australian Radiation Incident Register or the New Zealand Office of Radiation Safety is a legal requirement, there is no national system for the reporting of events involving lower radiation doses and near misses. Such national systems would enhance shared learning and improve the quality of radiation therapy. Some countries, including the United Kingdom and Canada, already have such systems. Several international bodies also provide systems for incident reporting, such as the International Atomic Energy Agency SAFRON system and the European Society for Therapeutic Radiation and Oncology ROSEIS system.

There are initiatives in both Australia and New Zealand to broaden national reporting of radiation incidents. The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) has established an Australian Radiation Incident Register Development Committee to develop requirements for data sharing and collection; guide development of an agreed set of reporting fields; and guide the software and database development for a prototype 'Australasian Radiation Incident Register 2.0'. The College is represented on this committee. In New Zealand, a National Incident Reporting Steering Committee has made recommendations to the Radiation Oncology Working Group on the requirement for a National Incident Reporting and Learning System. Work has commenced on incorporating this into the new Ministry of Health Common Regulatory Platform.

Key requirements for successful systems include independent governance, anonymised patient data, protection of the privacy of radiation treatment providers, regular analysis of data to identify trends, and regular reporting of important findings to contributors. Reporting of events (other than that required by existing legislation) should be voluntary. The ability of contributing institutions to analyse their own data and to benchmark against data of other providers would enhance the learning value of the system and encourage participation.

Data fields should be the same as those in international systems or should have the potential to be mapped to them, to allow comparison with other jurisdictions and international benchmarking. It is particularly important that the data collected in Australia and New Zealand are compatible, given our shared professional bodies, professional standards and radiotherapy culture. Ultimately, a binational database may be feasible.

Ideally all incidents will be reported, including near misses, as there is just as much to be learned from potential and minor events as from those that have significant consequences for patients. We should not have to wait until a patient is harmed before drawing lessons from the failure of our systems. Furthermore, the inclusion of minor events will increase the number available for analysis and the potential of the register to deliver useful information to improve safety. In order to minimise the burden of reporting large numbers of events, it will be important to link national registers with intradepartmental reporting systems where they are already captured.

Radiation safety is essential in all that we do as radiation oncologists and the national collection of incident data will improve the quality of care that we provide.

Dr Iain Ward

Quality Improvement Committee