ESTRO 2025 - Abstract Book

S4300

RTT - Service evaluation, quality assurance and risk management

ESTRO 2025

Conclusion: While the MRI-Linac workflow offers a streamlined solution, the Virtual MR-Linac workflow, despite its current significantly longer adaptation phase, allows for flexibility in resource utilization by decoupling a simulation MRI and radiotherapy delivery. Although further optimization through automation and standardization is required, this separation could potentially support a higher patient throughput through parallelization. Reserving the MRI-Linac for cases that benefit from intra-fraction tumor monitoring, while using Virtual MR-Linac for cases that can tolerate longer adaptation times, may enhance resource efficiency and treatment quality across both workflows.

Keywords: Adaptive Radiotherapy, MRI-Linac, Hybrid Workflow

2777

Proffered Paper Systems thinking in practice – lessons from a national incident learning system

Helen Best, John Rodgers, Cristíona Logan, Úna Findlay Medical Exposures Group, UKHSA, Oxford, United Kingdom

Purpose/Objective: Incident learning systems (ILS) are a widely accepted safety tool internationally advocated by professional groups, bodies, agencies, and regulators in radiotherapy 1,2 . Since its inception in 2008 the UK national voluntary ILS has received over 110,000 radiotherapy event (RTE) reports from every NHS radiotherapy provider, using a nationally agreed coding taxonomy (figure 1). Recently there has been a growing shift away from blaming individuals involved in healthcare incidents towards an increasing focus on understanding the underlying factors of how these incidents happen 3 . For example, SEIPS, a systems approach investigation framework with embedded human factors principles, has been adopted within the NHS 4 . The UK national voluntary ILS provides an ideal forum to analyse how multifactorial drivers contribute to failure of radiotherapy work systems. Identified associations can be used to inform targeted safety improvement efforts. This study aimed to interrogate the national ILS to establish patterns of associations between contributory factors (CF) and different stages within the patient pathway via the use of heat mapping.