Transcript Dia 1

PRISMA-RT a collective in the
radiotherapy in the Netherlands
Petra Reijnders M.A
manager patientsafety MAASTRO clinic and
secretary PRISMA-RT
septembre 2010
content presentation
“Past, present and future”
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Who are we ?
How did we start ?
Development until now !
Opportunities ?
association between
17 radiotherapy
departments
www.prisma-rt.nl
how did we start?
Why did MAASTRO became pioneer
in 2002?
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Organisational changes
Technology-push
Standardisation versus individualisation
MAASTRO development
Incidents
Masterthesis 2003
What is special in
the radiotherapy ?
1. Misses
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Overdose: healthy tissue is damaged
Underdose: tumor not optimal treated
(recidive )
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Wrong location (combination of above)
2. Visuality of the incidents
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Late effects
group of patients
3. High tech complex care
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Strong process standardization
Technique-human inter phase
Rapid innovation within radiotherapy
New safety mindset
Humans make mistakes but the environment,
the technique and organization can enhance
or reduce the mistakes
What do we want
with reports =
LEARN
• Goal: analyses-results and
effective actions
• Insight on failure modes and
root causes to prevent
system deviations
• Not intervene based on 1
incident but look for trends
PRISMA - model
Prevention and Recovery
System
for Monitoring and
Analysis
developed by
prof. T.W.v.d Schaaf
patient data exchange
Patient irridiated with data of
an other patient
after summon patient A
patient B entered
Patient
mistaked in
hearing his
name
Patient was
waiting for a
long time
Patient was
deaf
it was
summoned
by an
intercom
PRF
TD
wrong verification of the
patient
Patient was
already in
the linac
room
the second
tean thought
that the first
team already
checked
the
communicati
on was
incorrect
HRC
change of teams during
the treatmentsession
OP
time was nog
enough
OM
Programme
was too full
TD
a machine
failure
OP
to many
things to do
during the
treatment
classification
of base causes
• Technical Failure (T):
T-EX,TD,TC,TM
• Organisatonal Failure (O):
O-EX,OK,OP,OM,OC
• Human Failure (H):
H-EX,HKK,HRQ,HRC,HRV,HRI,HSS,
HST
• Patient Related factor: PRF
30.0%
15
1
5.0%
0.0%
HRC
OK
HKK
OC
HSS
TM
PRF
HRQ
TC
O-EX H-EX
Wie heeft gemeld in 2008?
AIO
DA
4%
2%
4%
TD
4%
OM
3%
OP
9%
HRI
KFG
diversen
ondersteuning
radiotherapeutisch laborant
RTO
74
%
HRV HRM
Trend aantal meldingen
Trend analyses total incidents
1835
1601
miss
654
09
89
20
20
85
63
08
109
07
129
05
20
04
122
1140
20
545
377
06
531
1835
1746
1515
510
20
660
aantal meldingen
near miss
1201
20
20
03
2000
1800
1600
1400
1200
1000
800
600 301
400
200 195
0 106
Amount of (near) incidents / month
trend misses
misses<5%
<5%or/ >5%
Trend
> 5% dosisafwijking
dosis deviation
140
120
128
118
100
108
86
80
afw <5%
75
60
77
52
40
20
27
0
2003
totaal miss
4
1
1
2004
2005
2006
11
9
2007
2008
afw >5%
70,0%
60,0%
50,0%
Human
Technical
Organisational
40,0%
30,0%
20,0%
10,0%
0,0%
2003
2004
2005
2006
2007
2008
Incident work flow (1)
* Thank note
* Read only incident
Incident
Mail informant
* Status incident
* Addition
* Mail RTO
* evt Mail AIO
Miss
* Mail MRT
Near
Miss
Epid incident
mail fysica
Mail
analists
Miss
Miss
Dosisdev. >5%
Dosisdev. <5%
Pre
Selection
Discussion
Incidentcom.
Incident work flow (2)
Bespreking
Meldingscie
Pre selectie
Ernst
Detecteerbaarheid
Brief naar
lijnverantw.
Op de hoogte
stellen en/of
Verzoek om actie!!!
Verzameling 1/2 jaar
soortgelijke
meldingen
Groeps
Analyse
Analyse verslag
naar lijnverantw.
Verzoek om actie!!!
Reguliere
PRISMA
Analyse
Kwartaal analyse per
Werkeenheid
Bespreking
Kwartaal analyse
met lijn verantw.
Bespreking
Kwartaal analyse
Werkeenheid
Analyse verslag
naar lijnverantw.
Verzoek om actie!!!
mile stones MAASTRO
2002: PRISMA-reporting system
2003: data statistics and pass on to colleague
departments
2004: first HFMEA/SAFER
2005: internal visitation and selective treatment
check
2006: culture: SAT training and PSO
2007: PVT team incl. policy plan
2008: VMS certificate & PRISMA-RT
development
2009: safety walkaround/revisitation by Lloyds
our Dutch pride
MAASTRO’s
VMS
PRISMA
related projects
Master university projects
• Costmodel: recovery in relation to the costs of reports
• Transitional risk effect research Electa -> Siemens
• Communication research with Siemens
Benchmark projects:
• collaboration Cath/ZRTI: patient identification and
datatransfer research
• OZRC : EPID process comparising using PRISMA
Prisma related national projects
benchmark data PRISMA radiotherapy
90
80
70
A
B
50
40
C
D
30
E
20
F
totaal abs
basisoorzaken PRISMA
PRF
HSS
HRI
HRC
HKK
OP
OC
-10
O-ex
0
TC
10
T-ex
aantallen
60
Advantages of a national
system
•confidence
•bigger amount of
contributors
•more individual
input
•more specific
organisational
improvements
decentral
central
National/sector
Figuur: T.W.v.d. Schaaf 4-11-2004
•big database in
shorter time period
•bigger analyse in
shorter time period
•bigger and faster
range of learning
moments (incl insight
about new risks)
conditions
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Uniform data comparising
PRISMA correctly
Database to make comparison possible
Interrater agreement test
Commitment organizations
Privacy protocol for data distribution
development
mile stones
nov-2003kwaliteitsconferentie OZRC: presentatie PRISMA methodiek door MAASTRO aan de 6 zelfstandige
radiotherapie instellingenApril t/m okt-2004PRISMA scholing aan de OZRC instellingeneind 2004 start van
samenwerkingsproject afd. Radiotherapie van Catharina, ZRTI, MAASTRO oa. op basis van PRISMA mbt de
processen: patientenidentificatie en datatransferjan-2005PRISMA scholing van de instelling NKI-AVL
2005tweetal benchmarkbijeenkomsten met OZRC instellingen mbt PRISMA datavergelijking PRISMA-RTjan2005afstudeer onderzoek PRISMA in het RISO ( B. van Raaij) + afsluitende presentatie voor alle PRISMA
geschoolde radiotherapieinstellingen gecombineerd met PRISMA casusbesprekingen van de instellingenjul2005bachelor onderzoeksproject mbt kostenrelatie van herstel bij incidenten in MAASTRO okt-2005afstudeer
onderzoek over risico's bij transitie ( J. Rutteman) + afsluitende presentatie voor alle PRISMA geschoolde
radiotherapieinstellingen gecombineerd met PRISMA casusbesprekingen van de instellingennov2005presentatie over PRISMA en samenwerkingsprojecten in het NVMBR jaar congresjan-2006bijeenkomst
PRISMA-radiotherapie in TU / PRISMA- herscholingjul-2006bijeenkomst PRISMA-radiotherapie in TU /
PRISMA- herscholingaug-2006eerste contacten NVZ mbt expertise over centrale database mogelijkhedenokt2006bijeenkomst PRISMA-radiotherapie tbv verdere samenwerking en het plan mbt centrale database
ontwikkelingfebr. 2007bijeenkomst PRISMA-radiotherapie met de presentatie van een rapport met de
vergelijking van firma's en databases. Tevens het ontstaan van de naam PRISMA-RT en het verder opzetten
van contacten met NVZ/DHD en het uitzetten van tekening intentieverklaringen. mei -2007formeel accoord
NVZ mbt samenwerking met PRISMA-RT.aug-2007afstudeer onderzoek apparatuur onderzoek MAASTRO
(J. Weterings) + afsluitende presentatie voor PRISMA radiotherapieokt-2007afronding van het
samenwerkingsproject afd. Radiotherapie van Catharina, ZRTI, MAASTRO oa. op basis van PRISMA mbt de
processen: patientenidentificatie en datatransferokt-febr 2008Oprichten binnen PRISMA-RT van de
expertgroep febr. 2008start implementatie GRECOM server bij NVZ/DHD mei. 2008eerste ledenvergadering
van de vereniging PRISMA-RTjuli /sep 2008scholing van de leden van PRISMA-RT van de database 7-okt2008bijeenkomst bestuur PRISMA-Rt/DHD/grecom mbt evaluatie traject implementatie. en afspraken mbt
acceptatie van de database door het expertteam22-nov-2008vereniging PRISMA-RT officieel de
domeinnaamhouder van prisma-rt.nl15-12-2008accepance door de pilot instellingen van de PRISMA-RT
database van Grecom22-12-2008aanmelding van Reinier de Graaf Groep als lid 2009Instellingen leren
werken met database en sluiten aan op het benchmark-deelAug 2009Site : www.prisma-rt.nl in de lucht31aug-09Presentatie ESTRO door Gytha Cuppen15 okt-09PRISMA-casus scholing en uitzetten van
interobservaribiliteitsonderzoekOkt-09Eerste benchmark data analyseNov 09Relaese updata database
2004: education OZRC PRISMA
2005: 2 benchmark projects &
master/bachelor research in
MAASTRO
2006: first inventarisation departments
2007: declaration of intent, NVZ contract partner
and location for the database, research for
commercial database, selection of
Grecom/TPSC
2008: foundation of expert team and start of
implementation of the database within the
departments, dec. 08: lid 17
may 08: formal first meeting of PRISMA-RT
2009: start data input, website on line, first
benchmark data available
membres of PRISMA-RT
1. Academisch Medisch Centrum, afdeling radiotherapie
2. Arnhems Radiotherapeutisch Instituut (Stichting Kankerbestrijding Arnhem en
omgeving)
3. Dr. Bernard Verbeeten Instituut
4. Catharina ziekenhuis Eindhoven, afdeling radiotherapie
5. Erasmus universitair Medisch Centrum Rotterdam,afdeling radiotherapie
6. HAGA ziekenhuis, afdeling radiotherapie, lokatie Leyenburgh
7. ISALA, afdeling radiotherapie
8. MAASTRO clinic
9. Medisch Spectrum Twente, afdeling radiotherapie
10. Nederlands Kanker Instituut - Antoni van Leeuwenhoek Ziekenhuis, afdeling
radiotherapie
11. VU Medisch Centrum, afdeling radiotherapie
12. Radiotherapeutisch Instituut Friesland
13. Radiotherapeutisch Instituut Stedendriehoek en Omstreken
14. Universitair Medisch Centrum Groningen, afdeling radiotherapie
15. Universitair Medisch Centrum Utrecht,afdeling radiotherapie
16. Zeeuws Radiotherapeutisch Instituut
17. Reinier de Graaf groep, afdeling radiotherapie
IMS/ PRISMA database
• 2005 first contact MAASTRO- Grecom/TPSC
• Development PRISMA-module and input of
MAASTRO
• 2006/2007 development SAFER-module
• End of 2006: TPSC database PRISMA-RT
• 2008: implementation & pilot TPSC database
• 2009: Cooperation Maastro/TPSC
Databenching ‘The Problems in the
past’
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Data collection was difficult
Data comparison took al long time
Plan a meeting
Discus data was learning process
Extent to other processes was almost
impossible
Control chart
A statistical tool used to differentiate
process deviations caused by:
1. normal process variation
2. variation caused by special causes
Why use control chart ?
• Monitor process variation during a period
• Differentiate between special & normal
variation
• Evaluate effects of process changes
• Communication tool for process
performance
Radiotherapie instelling A
Radiotherapie instelling B
Radiotherapie instelling C
Radiotherapie instelling ...
Instance
Instance
Instance
Instance
Radiotherapie instelling A
Radiotherapie instelling B
Radiotherapie instelling C
Radiotherapie instelling ….
Incident Management
Systeem
Incident Management
Systeem
Incident Management
Systeem
Incident Management
Systeem
Dedicated Server 1
Geanonimiseerde Data
Geanonimiseerde Data
Radiotherapie Benchmarkpunt
middels GreCom Rapportagetool
Geanonimiseerde Data
Geanonimiseerde Data
Benchmark database
Dedicated Server 2
Databenching ‘The Future’
Interrator reliability
– Lokal
– confirm reliability database
– meassure the performance analysts
– Collective
– unables oppertunity to improve knowledge to analyse
– improve the reliability of the collective data
– uniformity of analyses and continuity of knowledge
Why use the
interobservariability
research
?
So departments are comparable
and speak the same language
Method LIBB
50 ad random base cause prescriptions
=> Percentages agreement between
observers/analysts
=> Comparing with gold standard of
classification codes
Results LIBB, 2009
Of 51 analysts, scores were compared of 14
departments
Agreement
• Base cause level: 69%
• Base cause level but only human causes
were combined: 87%
• Main cause level: Human, Org and
Technical: 90%
Results LIBB, 2009
Beschrijving basisoorzaak
Gouden
standaar
d
Frequenti
e gouden
standaard
in %
Modus /
Modale
codering
Frequenti
e van de
modus in
%
hrv
58
oc
5
Bij controle van gegevens, is
automatisch aangenomen dat gegevens
correct zijn omdat iemand anders
gegevens afgetekend heeft
3
0
Behandelend arts vergeet door te geven
aan administratie dat patient
opgenomen ligt en dus niet voor CT en
bestraling komt
hrc
20
hri
65
3
3
Administratie geeft patient niet door dat
zijn tijdstip van bestraling is veranderd
h-ex
16
prf
69
1
5
epid-beelden hebben een zeer slechte
beeldkwaliteit, moeilijk te matchen
tm
34
td
42
3
5
Fysicus schat situatie op versneller
verkeerd in
hri
8
oc
30
4
1
Patientgegevens onterecht opgeborgen
zonder dat er boostplan van patient
gemaakt is
tm
29
td
37
1
0
geen eenduidigheid in communicatie
overdracht van voorbereiding naar
versneller. Verschillende formulieren
werken verwarrend
op
45
op
45
24
Conclusion LIBB
- Sufficient /Good agreement of 69%
- Differences are focussed within the
Human classification codes
Recommendation LIBB 2009
- Individual education for the low scoring
analysts
- Periodically repeating of LIBB
Databenching ‘The Future’
• Definition of context variables?
• Datamining/ Textmining?
• Comparing more data/information ?
(HFMEA)
• Eliminate the influence of the culture of
reporting
Databenching ‘The Future’
• Departement A starts implementing a new
process
• Conduct a HFMEA/SAFER
• Comparing HFMEA with the national PRISMAdatabase
• Discover problems of collegae departments and
use this information to complete the pro-active
riskanalyses.
• Department A learns anticipates on this
information during further implementation.
Mission
“Safe irridiation in every
radiotherapy department !!”
SLOGAN???
Databenching ‘The Future’
• PRISMA-RT (Belgium,Germany / Denmark)?
• PRISMA-RT (Europe)?
• PRISMA-RT (world)?
PRISMA
Law protection in Nederlands
• no legislation for data protection of a database
for reporting
• case NL: a calamity has to be reported to the
national inspection on health care. The patient
file did not have any information about the event.
Hereby other information was claimed.
• In MAASTRO data of reports are made
anonymous after 3 mounts when the analyses is
conducted
Extra info
The main conclusion is that only calamities gives the ligal
opportunity to ask for the available information from a
database of incidents. So at the moment the databases
are not immune for juridicairy actions. In my organization
we have a database of reports. Every 3 months the
reports are made anonymous so the information about
the person, who has put in the report, is erased. All the
other information about patient and context is still
available.
By my knowledge, the time period, by which the persons
information is erased, is not been defined in the
Netherlands.
The information from our minister of Health Dr. Klink: He
does not want to change the law to protect the person
who report because the document (beleidsdocument
veilig melden ) is sufficient according to him.