Quality Management 2017

Fishbone analysis in Radiotherapy

Example: patient switched with another patient, wrong treatment administered Value for the patient: right treatment, patient safety!!

= patient

= staff

No unique name

Didn’t check name

Poor hearing

Override for Table interlock

Many patients

Didn’t check DOB

Unable to respond

Same treatment area

No visual recognition

PATIENTS EXCHANGED

No independant check a priori; name

No interlock / check patient

No link patient/treatment

No table interlock

Imaging analysed after treatment

No SOP

Continuous Improvement

Methods

Incident Registration Discussion