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Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety  Gary Ezzell, PhD, Bhisham Chera, MD, Adam.

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Presentation on theme: "Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety  Gary Ezzell, PhD, Bhisham Chera, MD, Adam."— Presentation transcript:

1 Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety  Gary Ezzell, PhD, Bhisham Chera, MD, Adam Dicker, MD, PhD, Eric Ford, PhD, Louis Potters, MD, Lakshmi Santanam, PhD, Sheri Weintraub, MS  Practical Radiation Oncology  Volume 8, Issue 2, Pages (March 2018) DOI: /j.prro Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

2 Figure 1 Fault tree leading to the problematic plan approved for treatment error. In each of the figures, a box represents a particular type of error. The number in parentheses in each box shows the number of events of that type in this data set. Hexagonal boxes represent standard quality control steps in the radiation oncology workflow. Figure 1 is divided into 3 parts for clarity. Figures 1A and 1B flow into Fig 1C. CT, computed tomography; 4D, 4-dimensional; MR, magnetic resonance. Practical Radiation Oncology 2018 8, DOI: ( /j.prro ) Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

3 Figure 1 Fault tree leading to the problematic plan approved for treatment error. In each of the figures, a box represents a particular type of error. The number in parentheses in each box shows the number of events of that type in this data set. Hexagonal boxes represent standard quality control steps in the radiation oncology workflow. Figure 1 is divided into 3 parts for clarity. Figures 1A and 1B flow into Fig 1C. CT, computed tomography; 4D, 4-dimensional; MR, magnetic resonance. Practical Radiation Oncology 2018 8, DOI: ( /j.prro ) Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

4 Figure 1 Fault tree leading to the problematic plan approved for treatment error. In each of the figures, a box represents a particular type of error. The number in parentheses in each box shows the number of events of that type in this data set. Hexagonal boxes represent standard quality control steps in the radiation oncology workflow. Figure 1 is divided into 3 parts for clarity. Figures 1A and 1B flow into Fig 1C. CT, computed tomography; 4D, 4-dimensional; MR, magnetic resonance. Practical Radiation Oncology 2018 8, DOI: ( /j.prro ) Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

5 Figure 2 Fault tree leading to wrong shift instructions provided to therapists error. CBCT, cone beam computed tomography; DRR, digitally reconstructed radiograph; IGRT, image guided radiation therapy. Practical Radiation Oncology 2018 8, DOI: ( /j.prro ) Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

6 Figure 3 Fault tree leading to the wrong shift performed at treatment error. RTT, radiation therapy. Other abbreviation as in Fig 2. Practical Radiation Oncology 2018 8, DOI: ( /j.prro ) Copyright © 2017 American Society for Radiation Oncology Terms and Conditions

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