ESTRO 2021 Abstract Book

S1435

ESTRO 2021

Conclusion Effective implementation of a RO specific ILS including near misses enhanced the safety culture in a RO department. The lack of feedback (post-COVID)had a negative impact on reporting rates. There’s a need to stimulate reporting from nurses and RO. While the areas of improvement are clearly identified, we need to develop effective strategies to address them. PO-1708 In-House Incident Learning System for FMEA Using Microsoft Sharepoints and Powerapps D. Soultan 1 , M. Bragg 1 , T. Thompson 1 , A. Hoover 1 1 University of Kansas Cancer Center, Radiation Oncology, Kansas City, USA Purpose or Objective We propose a simple in-house internal incident learning system utilizing available Office 365 features; Sharepoints and Powerapps. The goal of the designed app is to periodically perform and update our Failure Modes and Effects Analysis FMEA prospective risk management for continuous quality improvement using collected data and failure information of processes and/or equipment that are encountered throughout our daily workflows. Materials and Methods We have broken down treatment workflows at our radiation oncology department by modality and technique. We chose Gynocological High Dose Rate (GYN HDR) Brachytherapy program as a starting point. A radiation oncologist, medical physicist, oncology nurse, therapist and practice director teamed up to discuss the GYN HDR process map,to review identified failure modes from old data, and to approve the preliminary ranking and risk priority numbers RPN derived from AAPM TG100. 6 failure types and 19 failure modes were mapped to the consequences that are compromising the patients' treatment. A Sharepoint list in Office 365 organization workspace was created and founded the database for the Powerapp. The Powerapp building step is mainly automated and allows customization and connection to multiple data sources including SQL and excel spreadsheets. Patient MRN is entered by the user, a date of the encounter is selected, and dropdown menus of preidentified failure modes, associated causes and consequences are built-in to choose from, in addition to a free text box to enter comments. Results The app was published for use by the GYN HDR Brachytherapy care team and being currently evaluated and more failure modes are being identified as more data are logged in. The next step is to expand the app to include all modalities and techniques in our department. Conclusion