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Session: Building a Better Safety Net [Return to Session]

Building a Better Safety Net

J Meyer1*, Y Rong2*, M Wells3*, S Evans4*, (1) University of Washington, Seattle, WA, (2) Mayo Clinic Arizona, Phoenix, AZ, (3) Piedmont Healthcare, Atlanta, GA, (4) Yale University, New Haven, CT


WE-H-BRC-0 (Wednesday, 7/13/2022) 4:30 PM - 6:00 PM [Eastern Time (GMT-4)]

Ballroom C

The well-known “Swiss Cheese Model” of accidents (Reasons et al.) suggests that employing several layers of error-proofing measures is an effective way to improve the quality and safety of care. Multiple quality measures acting synergistically enable us to “build a better safety net”. This session will explore three specific error-proofing measures in the context of radiation oncology: 1) surface-guided radiation therapy (SGRT), 2) standardization of nomenclature, processes and procedures, 3) physics plan and chart review à la TG-275/MPPG11a, and 4) departmental automation and integration. We will explore how these measures work independently and together. Finally, drawing from eight years of data and experience from the incident learning systems like the AAPM-sponsored RO-ILS: Radiation Oncology Learning System and the IAEA’s SAFRON we will explore the ways in which multiple quality measures can work together to build a better safety net.

Learning Objectives

1. Appreciate the value of SGRT for preventing errors

2. Understand the value of standardization and automation in preventing errors and improving quality

3. Learn ways to improve physics plan and chart review from TG275/MPPG11a and beyond

4. Recognize the ways in which multiple safety measures work in combination to prevent errors



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