Quality Management 2017

Fishbone analysis

Possible solution should be sought in Machine and/or Method: Man is never 100% safe, Material is not within circle of influence

Poor hearing

Many patients

Override for Table interlock

Patient: not within influence

Didn’t check DOB Human error

Unable to respond

Same treatment area

No visual recognition

PATIENTS EXCHANGED

No independant check a priori; name

No interlock / check patient

No table interlock

No link patient/treatment

Imaging analysed after treatment

No SOP

Continuous Improvement :

Methods

Incident Registration Discussion