Quality Management 2017

To Incident Quality System

Renamed: Incident Registration System (IRS) > Incident Quality System (IQS) - Not just reporting, also Prisma analysis and actions to improve quality

Prisma analysis of near-miss:

Almost wrong treatment administered

Near miss:

Facts prior to near miss:

Incomplete data in V&R system

Technologist notices missing parameter before start treatment

No SOP prior to start treatment on correct data

repair

Check entry V&R system failed

Parameter forgotten in V&R system

Causes:

Causes classified in T=technical, HR= human, O=organizational

Continuous Improvement: Methods

Incident Registration

Discussion