Technical Meeting on Strengthening Safety Culture through the Use of Incident Learning Systems

40 participants from 30 Member States and 10 international organizations gathered in Vienna to discuss and find ways to strengthen safety culture in radiotherapy thorough the use of incident learning systems.

Incident reporting and learning systems for gathering information on medical events and near events take on many different shapes and dimensions. Representatives from government regulatory authorities, professional organizations and radiotherapy facilities shared their experiences in using incident reporting and learning systems. Participants without a learning system were encouraged to participate in a system that best meets their needs.

The discussions during the meeting indicated that there continues to be challenges to implementing incident learning systems because of local culture where medical professionals do not easy admit errors for fear of retribution.

For those facilities participating in incident learning systems, there has been a positive response to the reporting of errors as “good catches” and an increase in the number of near events, indicating increased awareness of the potential of errors and seen as a positive outcome preventing harm to patients. Incident learning systems have been used in radiotherapy for the past 15 years with ROSIS being the first internationally shared system.

SAFRON, the IAEA system was established just 5 years ago and there continues to be an increase in the number of contributors and incidents reported. As the positive aspect of using an incident learning system continues, more activities to strengthen the safety system can be identified. There is a need to encourage the use of incident learning systems in a non-punitive environment.

Recommendations from the meeting included strengthening the role of radiotherapy leaders in supporting a strong safety culture in radiotherapy,  the continued collaboration between of the various incident learning systems by sharing newsletters and reports, to evaluate the need for an alert system where significant transboundary events that have a negative impact on patients can be shared between incident learning systems and radiotherapy facilities and a commitment to continue to work together to strengthen safety culture in radiotherapy.



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