232 - Optimized Hybrid Model for Radiation Incident Reporting in Multi-Site Centers

X. Li¹, R. Rahimi², F. C. Su³, A. K. Chawla¹, A. Miner¹, and J. Fan¹; ¹Inova Schar Cancer Institute, Fairfax, VA, ²University of Maryland, Baltimore, MD, ³University of Texas Southwestern Medical Center, Dallas, TX

Purpose/Objective(s): Conducting a radiation incident review in large radiation oncology systems with multiple sites presents significant challenges in terms of time and resources. In this study, we share our experiences in managing a radiation incident report system (RIRS) with a hybrid model, demonstrating the benefits and potential of this approach. Materials/

Methods: Our health system operates a network of 5 clinics, treating approximately 250 to 300 patients per day, using a wide spectrum of modalities including EBRT, brachytherapy and proton therapy. A departmental RIRS committee reviews reported events bi-weekly using a hybrid model consisting of two components: an internal system for reporting events and conducting statistical analysis, and commercial software for root cause analysis (RCA). The internal system, accessible online, centrally collects safety events reported by all staff. Events were categorized by site, treatment modality, harm score, and type, aligning with the established RO-ILS framework. The commercial tool offers institution-specific and prospective risk assessment following AAPM TG-100 guidelines. For cases requiring detailed review, we established FMEA risk assessment workflows within the software and trained it with previously reported events to generate insights into potential changes related to revenue, cost, and staff resource allocations.
Results: Between July and December 2023, we analyzed 84 radiation safety events using the hybrid model (see Table 1). Approximately 9.5% of the events required in-depth review sessions, including 5 photon cases and 3 proton cases. Detailed reviews were initiated based on two criteria: a harm score other than “no harm” or selection by the committee. The FMEA workflow identified preventative measures to mitigate potential risks. Upon adoption of these measures, the software forecasted a potential 5% to 10% decline in the occurrence of future events. This predictive assessment remains dynamic and subject to refinement, incorporating forthcoming reported events and implementing workflow revamps.
Conclusion: The hybrid model offers institution-specific and prospective risk management, resulting in enhanced efficiency in safety event review and optimizing management resources. It shows promise for cost reduction through RCA and workflow improvements, while maintaining a unified standard in reviewing safety events across multiple sites and settings. Abstract 232 – Table 1

Multi-site contributions to reporting
Main site	Satellite A	Satellite B	Satellite C	Satellite D
57.1%	8.3%	23.8%	6.0%	4.8%
Treatment modalities included in reporting
Brachytherapy	Radiopharmaceutical	Photon	Proton	Others
16.7%	0.0%	47.6%	16.7%	19.0%
Types of incidences
Therapeutic Radiation Incident	Other Safety Incident	Near miss	Unsafe condition	Process Improvement	Irrelevant
10.7%	14.3%	26.2%	13.1%	26.2%	9.5%
Harm score
No harm	Mild/Temporary harm	Severe/Permanent harm		Death
89.7%	10.3%	0.0%		0.0%