ESTRO 2025 - Abstract Book

S2353

Interdisciplinary – Other

ESTRO 2025

PRECIS-2, and definitions of pragmatism may vary. We propose a classification scheme for oncology pragmatic trials into broad archetypes to understand the driving pragmatic element(s), which may be used with or without PRECIS-2.

Keywords: Pragmatic trials, PRECIS-2

917

Digital Poster Root cause analysis of significant events and near misses in radiotherapy – a single institutional study Colin Kelly 1 , Susan Traynor 2 , Naomi Lavan 3 1 Physics, St Lukes Radiation Oncology Network, Dublin, Ireland. 2 Radiotherapy, St Lukes Radiation Oncology Network, Dublin, Ireland. 3 Radiation Oncology, St Lukes Radiation Oncology Network, Dublin, Ireland Purpose/Objective At SLRON all events and near misses are managed through the incident learning system (ILS). Events classified as minor are simply recorded and analysed on an annual basis for clusters and trends. Serious or potentially serious incidents are individually investigated using systems analysis (SA) to determine root cause (RC) and contributory factors (CF). The purpose of this study is to describe the systems analysis approach and to retrospectively present the results from 43 cases. Material/Methods Each case was investigated by the incident learning committee (ILC) comprising a clinician, radiation therapist and medical physics expert (MPE). This took the form of four steps as follows: (i) classification and categorisation (ii) dosimetric review (iii) detailed chronology of events and (iv) evaluation of RC and CFs using SA and Ishikawa diagrams. An example from one case is presented below:

6 factors were chosen for analysis in the diagram as follows : Equipment, Process, Policies, Human, Environment and Education. Similarly, domains from where the events originate and are detected are identified.

Results 43 incidents were assessed, reported over a 3 year period (2021-24). 25/43 were events that reached the patient and 18/43 were near misses. 17/43 were deemed reportable to the competent authority (CA). In 40/43 cases the root cause was determined as human error, 1/43 process and 2/43 equipment. A total of 71 CF’s were identified for the 43 events and were categorised as Human (34%), Environmental (24%), Process (21%), Education (10%), Policies (7%) and Equipment (4%).The most common domain for origination of events was Treatment (19%) followed by Planning (10%) and Target Definition (8%). Detection of events occurred most frequently on Treatment (43%), at Physics Review (31%) at RT Review (12%) and at Medical Review (10%)