Diseño de un sistema local de notificación y aprendizaje de sucesos en radioterapia basado en SAFRON

Carlos  Prieto Martin; Paula García Castañón; Rocío Simón de Blas; Sergio Honorato Hernández; Paloma Botella Faus; Pablo Chamorro Serrano; Rodrigo Rosado del Castillo

doi:10.37004/sefm/2023.24.1.001

Authors

Carlos Prieto Martin https://orcid.org/0000-0002-0535-6562
Paula García Castañón
Rocío Simón de Blas https://orcid.org/0009-0003-6141-7459
Sergio Honorato Hernández
Paloma Botella Faus https://orcid.org/0009-0008-6014-8812
Pablo Chamorro Serrano https://orcid.org/0009-0009-6681-5820
Rodrigo Rosado del Castillo https://orcid.org/0009-0003-5371-1543

DOI:

https://doi.org/10.37004/sefm/2023.24.1.001

Keywords:

ILS, Incident learning system, SAFRON, Safety in Radiotherapy

Abstract

Regardless of reporting events to general incident learning systems, a local incident learning system is required. With these local systems, events can be analysed and specific actions adapted to the specific workflows and technologies available in each Service can be designed. The design of these local systems requires a significant effort and must be carried out in such a way that it is easy to report and that all the necessary information is recorded for subsequent analysis. In this work, the design of a local incident learning system based in a web form, with the SAFRON structure is presented, showing the advantages compared to other possible options.

References

Committee on Quality of Health Care in America-Institute of Medicine. To Err Is Human: Building a Safer Health System. (The National Academies Press, 2000).

Radiation Offers New Cures, and Ways to Do Harm - The New York Times. https://www.nytimes.com/2010/01/24/health/24radiation.html

Bogdanich, W. A Pinpoint Beam Strays Invisibly, Harming Instead of Healing. The New York Times (2010). https://www.nytimes.com/2010/12/29/health/29radiation.html

DIRECTIVA 2013/59/EURATOM DEL CONSEJO de 5 de diciembre de 2013 por la que se establecen normas de seguridad básicas para la protección contra los peligros derivados de la exposición a radiaciones ionizantes. L13/1-73 (2014)

Real Decreto 601/2019, de 18 de octubre, sobre justificación y optimización del uso de las radiaciones ionizantes para la protección radiológica de las personas con ocasión de exposiciones médicas. 120840–120856 (2019)

Estrategia de Seguridad del Paciente del Sistema Nacional de Salud (2015-2020). https://www.seguridaddelpaciente.es/resources/documentos/2015/Estrategia Seguridad del Paciente 2015-2020.pdf (2015)

Radiation Protection No 181: General guidelines on risk management in external beam radiotherapy. http://ec.europa.eu/energy/sites/ener/files/documents/RP181.pdf (2015)

T. Pawlicki, M. C. and M. M. Incident Learning Systems for Radiation Oncology: Development and Value at the Local, National and International Level. Clin. Oncol. 29, 562–567 (2017). DOI:https://doi.org/10.1016/j.clon.2017.07.009

IAEA. Safety in Radiation Oncology (SAFRON). https://rpop.iaea.org/RPOP/RPoP/Modules/login/safron-register.htm

Radiation Oncology Safety Education and Information System. https://roseis.estro.org/

Comunicación de Incidentes de Seguridad y Errores de Medicación. https://cisemadrid.salud.madrid.org/index.htm

Sistema de Notificación y Aprendizaje para la Seguridad del Paciente (SiNASP). www.sinasp.es

ASN & ANSM. Vigie Radiothérapie. http://vigie-radiotherapie.fr/?action=reglementations

PRISMA-RT. http://www.prisma-rt.nl/index-eng.html

World Health Organization. Radiotherapy Risk Profile. Technical manual. http://www.who.int/patientsafety/activities/technical/radiotherapy_risk_profile.pdf (2008)

British Institute of Radiology; Institute of Physics and Engineering in Medicine; National Patient Safety Agency; Society and College of Radiographers; The Royal College of Radiologists. Towards Safer Radiotherapy. https://www.rcr.ac.uk/system/files/publication/field_publication_files/Towards_saferRT_final.pdf

David L, Cooke, Meina Dubetz, R., Heshmati, Sandra Iftody, E. M., Jodi Powers, Robert C. Lee, P. B. & Dunscombe. HTA initiative 22: A reference guide for learning from incidents in radiation therapy. http://www.ihe.ca/documents/HTA-FR22.pdf (2006)

World Health Organization. Conceptual framework for the international classification for patient safety. v 1.1 http://www.who.int/patientsafety/implementation/taxonomy/publications/en/index.html (2009)

Augusto Radicchi, L., Carlos de Toledo, J. & Henrique Alliprandini, D. Critical success factors for implementation of an incident learning system in radiation oncology department. Reports Pract. Oncol. Radiother. 25, 994–1000 (2020). DOI: https://doi.org/10.1016/j.rpor.2020.09.014