ESTRO 2025 - Abstract Book

S3588

Physics - Quality assurance and auditing

ESTRO 2025

risk management meetings and guided targeted interventions. Analysis focused on incident frequencies and the workflow steps where errors originated versus where they were detected. When specific issues escalated, a Failure Mode and Effects Analysis (FMEA) was conducted to prioritize failure modes and implement corrective actions, such as introducing new safety barriers or refining existing measures.

Results:

The system improved responsive incident reporting and effective tailoring of risk management strategies, collecting a total of 207 incident reports since 2019. Data analysis revealed critical gaps where errors bypassed safety barriers, allowing for targeted countermeasures. Since implementing data-driven risk management in 2019, the average time between incident occurrence and detection was reduced by half, from initially a mean of 6.1±4.2 process steps down to a mean of 2.9±3.2 process steps (see Figure). This underlines the effectiveness of risk management initiated measures taken to improve safety barriers. Resource analysis highlighted the need for adequate allocation; system development required approximately 150 hours, and ongoing risk management activities demanded about 20% of a full-time equivalent position. Conclusion: The web-based incident reporting system has significantly advanced risk management in radiation oncology at our clinic, enhancing safety through real-time analytics and ensuring legal compliance. Effective identification and mitigation of risks have strengthened safety barriers, underscoring the importance of sufficient resource allocation to maintain and improve clinical safety practices.

Keywords: risk management, fmea, data-driven

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Digital Poster Evaluation of target offset compensation robustness using jaws and binary MLC in Radixact Synchrony tracking system: A phantom study Masatoshi Miura 1 , Koji Sasaki 2 , Yasuo Shiota 1 , Kazuyasu Inoue 3 1 Iwata City General Hospital, Department of Medical Physics, Iwata, Japan. 2 Gunma Prefectural College of Health Sciences, Graduate School of Radiological Technology, Maebashi, Japan. 3 Iwata City General Hospital, Department of Radiation Technology, Iwata, Japan Purpose/Objective: The Radixact system incorporates target tracking and real-time motion synchronization to manage intrafractional motion. It compensates for target motion along the IEC-Y direction using jaws, while binary multi-leaf collimator