The Liverpool system - classification, learning & prevention

1. Incident Reporting and Learning: The Liverpool system - classification, learning & prevention Anthony Arnold Director Cancer Services, Illawarra Shoalhaven Local Health District Anthony.Arnold@sesiahs.health.nsw.gov.au

2. Context

3. The Liverpool System Ref: IJROBP 2010 Volume 78, No 5, Pages 1548-1554

4. A Problem Worth Solving…… • Complexity of radiation oncology • At the time no system of analysis was in place • Lack of clinical governance surrounding reporting • There was limited openness about reporting events • The culture was predominantly blame based • Standard reporting systems are ineffective for radiation oncology

5. Classification

6. Prescription Simulation Computing Pre-Treatment Treatment Bolus Shielding / MLC Imaging Documentation

7. Classification Advantage

8. Error / Event Definitions • Event: • “event or circumstance which could have resulted, or did result in harm to a patient” • Actual Error: • “Error resulting in radiation exposure other than that intended or prescribed – correctable or otherwise” • Near Miss: • “Error or non-conformance detected before reaching the patient”

9. High Level Structure…….PDSA

10. Reporting and Managing an Event

11. Department Analysis

12. Results - Initial Pilot • 688 reports were logged during the study period • 155 Actual errors (23%) • 533 Near Miss (77%)

13. Results - Subsequent Pilot • 670 reports were logged during the study period • 67 Actual errors (10%) • 603 Near Miss (90%)

14. Time Trends Statistics Ref: Simple Interactive Statistical Analysis online statistical calculator. Available at: http://www.quantitativeskills.com/sisa/statistics/t-test.htm. Accessed 29 January 2008

15. Time Trends Statistics Ref: Simple Interactive Statistical Analysis online statistical calculator. Available at: http://www.quantitativeskills.com/sisa/statistics/t-test.htm. Accessed 29 January 2008

16. Time Trends 1st Pilot: Attendances

17. Time Trends – 2nd Pilot: Courses

19. Outcomes – Key Measures

20. Patient Safety Risk Improvement • REDUCTION IN REPORTED EVENTS as a function of attendances • Actual Error rate reduced from 0.26% to 0.08% (p=0.0017) • Near Miss rate reduced from 2.33% to 1.01% (p<0.0001) • IMPROVED RELATIVE PATIENT SAFETY RISK per treatment course • Actual error rate reduced from 1 in 19 courses to 1 in 75 courses; in other words from 5% down to 1.3% risk of detectable error (p=0.0003) • Near miss rate reduced from 1 in 2 courses to 1 in 6 courses; in other words from 50% down to 17% (p<0.0001)

21. Thank you