ESTRO 2025 - Abstract Book

S2354

Interdisciplinary – Other

ESTRO 2025

Conclusion RCA is an effective method for determining key causal and contributary factors for significant events. A consistent approach requires trained and experienced staff and for reasons of workflow and resources should be confined to only those events deemed serious by local ILC's. It should be noted that during the period of this study 16,651 patients were treated at our institution. Significant events thus represent <0.26% of the patient population emphasising the safety of the radiotherapy process. This study highlights however the significant contribution of human error as a causal and contributary factor and highlights the increased need for automation of processes to mitigate risk.

Keywords: Incidents, root, analysis

References Brook O, Root Cause Analysis: Learning from Adverse Safety Events. Radiographics. Oct;35(6):1655-67 (2015). doi: 10.1148/rg.2015150067. HSE Incident Management Framework 2020 HSE - Incident Management Framework and Guidance 2020

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Digital Poster The road to successful implementation of innovation in radiotherapy: a research-based protocol Fiona Ho 1 , Rachelle Swart 1 , Paul Cremers 1 , Rianne Fijten 2 , Liesbeth Boersma 1 , Maria Jacobs 3 1 Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastro, Maastricht, Netherlands. 2 Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht University, Maastricht, Netherlands. 3 Tilburg School of Economics and Management, Tilburg University, Tilburg, Netherlands Purpose/Objective Radiotherapy (RT) is advancing quickly, necessitating timely implementation of innovations to improve treatment precision and patient outcomes. However, only 50% of innovations are timely implemented. Despite the availability of Implementation Science (ImpSci) theories, models, and frameworks (TMFs), a theory-practice gap remains in effectively using insights from ImpSci in clinical practice in RT. To bridge this theory-practice gap, this study aims to develop an implementation protocol for RT innovations, based on validated ImpSci knowledge. Material/Methods The study started with a literature review of existing TMFs (May-August 2023), followed by 20 semi-structured interviews (August-December 2023) with Dutch RT professionals (from 14 departments) to identify key RT components for implementation. Insights from literature and interviews were used to draft a RT implementation protocol. This protocol was refined through an international, three-round Delphi study (March-September 2024) involving 11 RT experts and 5 ImpSci experts. Consensus was determined using a 5-point Likert scale, calculating each element's median, interquartile range (IQR), and percentage scoring. Results Results from the literature search prompted using the Knowledge-to-Action (KTA) Framework during the interviews to outline a RT implementation protocol for the Delphi study. Response rates were 100%, 93.8% and 88.9% for each round. In Round 1, consensus was achieved for 88.9% of the elements (median=4.0, IQRs=0.0-1.3), with step 3c identified for revision (median=3.5, IQR=1.0). In Round 2, 66.7% of the elements reached consensus (median=4.0, IQR=0.5-1.0), and 22.2% achieved full consensus (median=5.0, IQR=1.0). Step 3c did not reach consensus (median=3.0, IQR=1.5). In Round 3, step 3c was refined, relocated to step 3, and reached consensus (median=4.0, IQR=0.3). All experts agreed on the relevance of all elements (Table 1). The protocol shows a roadmap for innovation implementation (Figure 1), starting with defining the innovation type and project initiation. When