ESTRO 2024 - Abstract Book

S5866

RTT - Service evaluation, quality assurance and risk management

ESTRO 2024

threats and consequences were defined and placed in a diagram. Then, barriers were determined, ways to prevent the threat or limit the consequences. The barriers were defined as existing or missing and analyzed for feasibility.

The three feared events were analyzed. The causes and consequences have been identified and distributed for the 3 risks. The number and effectiveness of preventive and corrective barriers were recorded. All data was collected through the completion of a questionnaire and discussions in multidisciplinary meetings around the answers provided.

Results:

In total, 17 causes, 10 consequences and 44 barriers contributed to the implementation of the 3 bow-tie models.

1. Incorrect patient identification bow-tie: we have identified 3 causes that could lead to the feared event. The analysis of this top event allowed us to determine 11 barriers (6 preventives and 5 correctives). Five are missing barriers and 5 practical recommendations can be done. For example, displaying the patient's photo and name in the bunker, asking for the patient's active participation in their identification. 2. Delivering the wrong dose: this analysis revealed 17 barriers, 4 of which are missing and led to 9 recommendations. One of them is the creation of standardized prescription templates. 6 causes were also highlighted. 3. Treating in the wrong localization: this bowtie showed 8 causes and 16 barriers (11 preventives and 5 correctives). These barriers led to 8 recommendations such as the respect of the time-out procedure.

Figure 1 represents one of the 3 bow-tie analysis models, that of the patient identification error.

Figure 1: bow-tie analysis of patient identification error.