[OA223] Establishing a unified system for logging radiation incidents in an international healthcare services organisation

Purpose Working in a dynamic, complex and high workload environment can lead to unintended radiation exposures. Unintended does not mean unable to prevent. Establishing a unified incident management system in an international healthcare services organisation facilitates better identification of safety critical steps. A bigger ‘pool of events’ can identify trends in incident types and maximize improvement opportunities across the whole system. Methods There is never a single cause for an incident to happen. The incident management system of the organization, AIMS, is a tool developed to log and learn from any adverse events that concern patients, staff or third-parties under the organization’s care. AIMS is not designed to be an administrative tool to find and penalise individuals, but to support collective learning within the organization network to prevent failures and avoid harm. AIMS is a digital platform accessible to all personnel to log incidents and good catches; incidents which were prevented, due to timely and competent personnel action. It is purposefully a four click process to promote easy and fast logging of events, including process stage, incident type and severity. Once an event is logged, approval of the information provided is required before investigation and analysis of the root causes that lead to the event are initiated. Results AIMS allows the process stage to be logged – that is, the stage in the journey at which the event occurred. In-depth investigation identifies failures in the often-complex healthcare environment, allows detection of risks and developing ways to reduce or eliminate the risk of reoccurrence. Good catches and incidents of moderate and above severity are shared with the group regularly as a learning process. Root cause analysis of events allows scrutiny of the preceding process stages, in order to identify contributory factors leading up to the event and definition of actions. Conclusions To Err is Human. We cannot change the human condition, but we can change the condition under which humans’ work. Incident management is a valuable tool to promote a safety culture and awareness through the involvement of and feedback to staff and managers.