Unusual occurrence reporting system: Sharing a ten years experience from a tertiary care JCIA accredited university hospital.

PURPOSE: Identifying a true measure of safety is challenging in radiation oncology. A culture of unusual reporting may however be used as an indirect measure for it. The purpose of this study is to share our experience of unusual occurrence reporting system, established in the Radiation Oncology section since 2006, the first of this nature in Pakistan. MATERIALS AND METHODS: Data is collected over the last ten years. An in-house online reporting system has been developed for reporting unusual events. All the reported events are evaluated retrospectively. The stage of unusual occurrence along the radiation therapy process, possible causes, severity and preventive measures taken are discussed. RESULTS: Analysis of the 501 unusual occurrences reported over the last ten years has shown a substantial decrease in the number of significant mistakes observed. Of the total, 57 % unusual occurrences have been reported by radiation therapy technologists, including treatment preparation processes. Oversight is supposed to be the most common cause for unusual occurrences. CONCLUSIONS: The ten years experience with reporting and documenting of unusual occurrences resulted in a safety culture where every individual is willing to share any type of incident with a free well. Our experience at the Aga Khan University Hospital (AKUH) shows that the major reason for the occurrence of incidents was oversight. The majority of unusual occurrences were reported by radiation therapy technologists, as expected, since they handle the bulk of the treatment planning process.

Everolimus induced Pneumonitis.

Everolimus (RAD 001) is an orally administered inhibitor of mTOR (mammalian target of rapamycin), a central regulator of intracellular signaling pathways involved in cell growth and proliferation, cellular metabolism and angiogenesis. Drug is currently in use to prevent allograft rejection after solid organ transplantation and in treatment of advanced renal cell carcinoma (RCC). Noninfectious pneumonitis is rare adverse reaction associated with rapamycin and rapamycin analogues. Awareness of this toxicity and appropriate management is important to optimize patient safety. Here we report a case of everolimus induced pneumonitis in a 72 years old male with metastatic renal cell carcinoma (mRCC) after 4 months of commencement of everolimus. Drug was discontinued and patient was treated accordingly and discharged after 10 days of hospital admission.