ESTRO 2025 - Abstract Book

S2304

Interdisciplinary – Health economics & health services research

ESTRO 2025

Results: The analysis revealed 131 potential failure modes within the entire radiotherapy process, with the macro-phase of "radiotherapy treatment" showing the highest number of errors (39, approximately 30% of the total). The risk priority numbers range from 2 to 24, with an average of 9, indicating an overall medium-low risk level. Notably, the "Contouring and prescription" phase has an average RPN of 17, highlighting its significant criticality. Among the most notable errors are the incorrect contouring of the lesion, the failure to contour or the incorrect contouring of at-risk organs, and the erroneous prescription of dose limits, as well as the inadequate positioning of the magnet on the pacemaker when necessary. To enhance safety and quality, specific strategies have been developed to mitigate risks, including process-oriented, educational and technological interventions aimed at strengthening the reliability of the entire workflow.

Conclusion: The application of the FMECA methodology identified critical issues within radiotherapy processes, providing the multidisciplinary team with tools to prevent errors and enhance the safety of the therapeutic pathway. This approach fosters a culture of shared responsibility and sustained attention to care quality. In two years, a follow-up analysis will evaluate the effectiveness of the corrective actions implemented, monitoring progress and identifying further optimization opportunities. This review cycle will not only improve the safety and quality of treatments but also encourage the team to share ideas and best practices, transforming each therapeutic experience into an opportunity for growth and innovation, aimed at delivering effective, deeply human and personalized care. References: Huq, M. S. et al. (2016). The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical physics , 43 (7), 4209. https://doi.org/10.1118/1.4947547 Giardina, M. et al. (2016). A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health physics , 111 (4), 317–326. https://doi.org/10.1097/HP.0000000000000536 Mancosu, P. et al. (2021). Critical Re-Evaluation of a Failure Mode Effect Analysis in a Radiation Therapy Department After 10 Years. Practical radiation oncology , 11 (3), e329–e338. https://doi.org/10.1016/j.prro.2020.11.002 Keywords: Risk management, FMECA, Radiotherapy