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PRISMA-RT a collective in the radiotherapy in the Netherlands

PRISMA-RT a collective in the radiotherapy in the Netherlands. Petra Reijnders M.A manager patientsafety MAASTRO clinic and secretary PRISMA-RT septembre 2010. Who are we ? How did we start ? Development until now ! Opportunities ?. content presentation “Past, present and future”.

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PRISMA-RT a collective in the radiotherapy in the Netherlands

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  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

  2. Who are we ? How did we start ? Development until now ! Opportunities ? content presentation “Past, present and future”

  3. association between 17 radiotherapy departments www.prisma-rt.nl

  4. how did we start?

  5. Why did MAASTRO became pioneer in 2002? Organisational changes Technology-push Standardisation versus individualisation MAASTRO development Incidents Masterthesis 2003

  6. What is special in the radiotherapy ? Misses Overdose: healthy tissue is damaged Underdose: tumor not optimal treated (recidive ) Wrong location(combination of above)

  7. 2. Visuality of the incidents Late effects group of patients 3. High tech complex care Strong process standardization Technique-human inter phase Rapid innovation within radiotherapy

  8. New safety mindset Humans make mistakes but the environment, the technique and organization can enhance or reduce the mistakes

  9. 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

  10. PRISMA - model Prevention and Recovery System for Monitoring and Analysis developed by prof. T.W.v.d Schaaf

  11. wrong verification of the patient after summon patient A patient B entered change of teams during the treatmentsession time was nog enough Patient mistaked in hearing his name Patient was waiting for a long time Patient was already in the linac room the second tean thought that the first team already checked Programme was too full Patient was deaf it was summoned by an intercom the communication was incorrect a machine failure to many things to do during the treatment patient data exchange Patient irridiated with data of an other patient OP OM TD PRF OP TD HRC

  12. 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

  13. 30.0% 15 1 5.0% 0.0% HRV HRM HRI OP OM TD HRC OK HKK OC HSS TM PRF HRQ TC O-EX H-EX

  14. Trend analyses total incidents 1835

  15. Amount of (near) incidents / month

  16. Trend misses <5% or > 5% dosis deviation

  17. Incident work flow (1) * Thank note * Read only incident Incident * Status incident Mail informant * Addition * Mail RTO * evt Mail AIO Miss Near * Mail MRT Miss Mail Miss Miss analists Dosisdev. <5% Dosisdev. >5% Pre Selection Discussion Incidentcom. Epid incidentmail fysica

  18. Incident work flow (2)

  19. 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

  20. our Dutch pride MAASTRO’s VMS

  21. 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

  22. Prisma related national projects

  23. Advantages of a national system • confidence • more individual input • more specific organisational improvements • bigger amount of contributors • big database in shorter time period • bigger analyse in shorter time period • bigger and faster range of learning moments (incl insight about new risks) decentral central National/sector Figuur: T.W.v.d. Schaaf 4-11-2004

  24. conditions Uniform data comparising PRISMA correctly Database to make comparison possible Interrater agreement test Commitment organizations Privacy protocol for data distribution

  25. development

  26. 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-RTjan-2005afstudeer onderzoek PRISMA in het RISO ( B. van Raaij) + afsluitende presentatie voor alle PRISMA geschoolde radiotherapieinstellingen gecombineerd met PRISMA casusbesprekingen van de instellingenjul-2005bachelor 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 instellingennov-2005presentatie 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 mogelijkhedenokt-2006bijeenkomst 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-okt-2008bijeenkomst 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 lucht31-aug-09Presentatie ESTRO door Gytha Cuppen15 okt-09PRISMA-casus scholing en uitzetten van interobservaribiliteitsonderzoekOkt-09Eerste benchmark data analyseNov 09Relaese updata database

  27. 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

  28. membres of PRISMA-RT Academisch Medisch Centrum, afdeling radiotherapie Arnhems Radiotherapeutisch Instituut (Stichting Kankerbestrijding Arnhem en omgeving) Dr. Bernard Verbeeten Instituut Catharina ziekenhuis Eindhoven, afdeling radiotherapie Erasmus universitair Medisch Centrum Rotterdam,afdeling radiotherapie HAGA ziekenhuis, afdeling radiotherapie, lokatie Leyenburgh ISALA, afdeling radiotherapie MAASTRO clinic Medisch Spectrum Twente, afdeling radiotherapie Nederlands Kanker Instituut - Antoni van Leeuwenhoek Ziekenhuis, afdeling radiotherapie VU Medisch Centrum, afdeling radiotherapie Radiotherapeutisch Instituut Friesland Radiotherapeutisch Instituut Stedendriehoek en Omstreken Universitair Medisch Centrum Groningen, afdeling radiotherapie Universitair Medisch Centrum Utrecht,afdeling radiotherapie Zeeuws Radiotherapeutisch Instituut Reinier de Graaf groep, afdeling radiotherapie

  29. 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

  30. Databenching ‘The Problems in the past’ 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

  31. Control chart A statistical tool used to differentiate process deviations caused by: normal process variation variation caused by special causes

  32. 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

  33. 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 Databenching ‘The Future’

  34. Why use the interobservariability research? • So departments are comparable and speak the same language

  35. Method LIBB 50 ad random base cause prescriptions => Percentages agreement between observers/analysts => Comparing with gold standard of classification codes

  36. 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%

  37. Results LIBB, 2009

  38. 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

  39. Databenching ‘The Future’ Definition of context variables? Datamining/ Textmining? Comparing more data/information ? (HFMEA) Eliminate the influence of the culture of reporting

  40. Departement A starts implementing a new process Conduct a HFMEA/SAFER Comparing HFMEA with the national PRISMA-database 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. Databenching ‘The Future’

  41. Mission “Safe irridiation in every radiotherapy department !!” SLOGAN???

  42. PRISMA-RT (Belgium,Germany / Denmark)? PRISMA-RT (Europe)? PRISMA-RT (world)? Databenching ‘The Future’

  43. PRISMA

  44. Questions?

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