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PRISMA-RT a collective in the radiotherapy in the Netherlands Petra Reijnders M.A manager patientsafety MAASTRO clinic and secretary PRISMA-RT septembre.

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Presentatie over: "PRISMA-RT a collective in the radiotherapy in the Netherlands Petra Reijnders M.A manager patientsafety MAASTRO clinic and secretary PRISMA-RT septembre."— Transcript van de presentatie:

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


5 how did we start?

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

7 What is special in the radiotherapy ? 1.Misses Overdose: healthy tissue is damaged Underdose: tumor not optimal treated (recidive ) Wrong location (combination of above)

8 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

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

10 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

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

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

13 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


15 Trend analyses total incidents 1835

16 Amount of (near) incidents / month

17 Trend misses 5% dosis deviation


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

20 Incident work flow (2)

21 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

22 our Dutch pride MAASTRO’s VMS

23 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

24 Prisma related national projects

25 Advantages of a national system decentral central National/sector 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) Figuur: T.W.v.d. Schaaf 4-11-2004

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

27 development

28 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 : in de lucht31- aug-09Presentatie ESTRO door Gytha Cuppen15 okt-09PRISMA-casus scholing en uitzetten van interobservaribiliteitsonderzoekOkt-09Eerste benchmark data analyseNov 09Relaese updata

29 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

30 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

31 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

32 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


34 Control chart A statistical tool used to differentiate process deviations caused by: 1.normal process variation 2.variation caused by special causes

35 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




39 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’

40 Why use the interobservariability research ? So departments are comparable and speak the same language

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

42 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%

43 Results LIBB, 2009 Beschrijving basisoorzaak Gouden standaar d Frequenti e gouden standaard in % Modus / Modale codering Frequenti e van de modus in % 5 Bij controle van gegevens, is automatisch aangenomen dat gegevens correct zijn omdat iemand anders gegevens afgetekend heeft oc24hrv58 3030 Behandelend arts vergeet door te geven aan administratie dat patient opgenomen ligt en dus niet voor CT en bestraling komt hrc20hri65 3 Administratie geeft patient niet door dat zijn tijdstip van bestraling is veranderd h-ex16prf69 1515 epid-beelden hebben een zeer slechte beeldkwaliteit, moeilijk te matchen tm34td42 3535 Fysicus schat situatie op versneller verkeerd in hri8oc30 4141 Patientgegevens onterecht opgeborgen zonder dat er boostplan van patient gemaakt is tm29td37 1010 geen eenduidigheid in communicatie overdracht van voorbereiding naar versneller. Verschillende formulieren werken verwarrend op45op45 1 De technici van de eigen instelling hebben de beperking van de versneller niet gecommuniceerd naar hoofdlaborant hrc45hrc45 1818 Arts is zich niet bewust en stelt laborant niet op de hoogte van wijziging fractioneringsschema maar alleen de adminstratie om het aantal afspraken te wijzigen Exclud. (te veel discuss ie HRC/ HKK) 33hrc33 2020 Hoe te handelen bij een specifieke storing van de versneller niet duidelijk voor alle laboranten op49op49

44 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

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

46 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’

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

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



51 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

52 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.

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