The Radiation Incident Safety Committee Incident Report Guidance Tree: A Tool to Support Provincial and National Incident Sharing

Aim: In the third quarter of fiscal year 2018, Ontario transitioned its radiation treatment incident reporting to the National System for Incident Reporting – Radiation Therapy (NSIR-RT). The NSIR-RT database provides users a platform for incident reporting and learning. Ontario Health, Cancer Care Ontario (OH-CCO) requires radiation treatment programs to report actual incidents, defined as events that have “reached the patient”. The submission of near miss events, although encouraged, are done so as per a program's available resources. Representative Radiation Incident Leads (RILs) from each centre triage incident reports for submission to NSIR-RT. OH-CCO's Radiation Incident Safety Committee (RISC) recognized this triaging of submitted events as an opportunity to create guiding principles to improve the consistency of the types of events reported nationally. The impetus for this initiative was to develop a guidance tree for RILs to classify events that reach the patient and subsequently identify those with significant interest and/or with greatest learning potential at a national level that should be submitted to NSIR-RT. Process: RISC members were surveyed to obtain feedback regarding current incident classification practices. Members were asked to classify case studies as actual, near miss or neither. Integrating survey results, a guidance tree was created in lieu of simply amending the definition of “reached the patient”. Introduced in June 2019, RISC was solicited for final feedback. The tool was then trialled and using an iterative process, finalized in June 2020. Benefits: The RISC guidance tree not only provides clarity as to when an incident “reaches the patient” and by extension identifies an actual versus a near miss event, but also guides centres in determining those incidents with the greatest potential for incident learning. The tool also promotes reporting consistency between centres and may support the maintenance of and or increased event reporting volumes. Finally, the guidance tree highlights those incidents that may provide valuable insights that can be leveraged for incident learning for other NSIR-RT users at provincial and pan-Canadian levels. Challenges: Further opportunities exist to refine the tool for incidents that prove challenging to classify. RILs are encouraged to share these events for discussion at RISC's regular quarterly meetings providing a mechanism for further refinement of the guidance tree. Outcomes: The guidance tree can support RILs in the triage event submission to NSIR-RT. An often complex and time consuming exercise, with limited program resources. Featured in the spring 2020 NSIR-RT bulletin, the tool can be leveraged by other jurisdictions to harmonize reporting. As RISC reviews its initiatives, using the lens of continuous quality improvement, a 2021 survey identified continued support and described a positive impact with respect to their program's incident reporting and learning. RISC plans to review and refine the tool as part of the committee's upcoming initiatives.