S1345
Interdisciplinary - Education in radiation oncology
ESTRO 206
oncology training: three-year experience of FMEA on CT simulation Pietro Mancosu 1,2 , Chiara Signori 3 , Damiano Dei 2 , Nicola Lambri 2 , Andrea Bresolin 2 , Luciana Di Cristina 2 , Lorenzo Lo Faro 2 , Beatrice Marini 2 , Antonio Marco Marzo 2 , Sara Stefanini 1,2 , Veronica Vernier 1,2 , Stefano Tomatis 2 , Ciro Franzese 1,2 , Marta Scorsetti 1,2 1 Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy. 2 Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy. 3 Risk Management Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy Purpose/Objective: Risk management is an essential component of radiation oncology education [1], also recommended by the Euratom 2013/59 directive. We report a three- year experience integrating structured Failure Mode and Effects Analysis (FMEA) into a residency program, focusing on the CT simulation process. The objective was to assess residents’ ability to identify critical risks and to evaluate the impact of a multidisciplinary “Time-out” intervention on process safety [2]. Material/Methods: Each year, first-year radiation oncology residents attended an 8-hour theoretical course and a 4-hour guided FMEA exercise supervised by clinical risk experts. Year 1: Six residents analyzed the CT simulation process, scoring severity (S: 1–5), occurrence (O: 1–4), and detectability (D: 1–4) for each failure mode (FM) and computing the risk priority number (RPN = S × O × D – range 1-80). Scores were compared with those from six expert radiation oncologists. Year 2: Two new residents repeated the procedure. Based on recurrent high-priority FMs, a multidisciplinary group (residents, oncologists, physicists, RTTs) designed and implemented a pre- simulation CT “Time-out” checklist targeting the highest RPNs. Year 3: The two cohorts repeated the FMEA to assess the effect of the Time-out procedure. Statistical comparison was performed using the Wilcoxon signed-rank test. Results: Across the three years, 44 FMs were identified. In Year 1, residents’ mean RPNs were comparable to experts (13.5 vs 13.6) but with greater variability (SD 9.0 vs 6.5). Year 2 results were similar (15.0 ± 7.3). Three, 11, and 37 FMs exceeded RPN values of 30, 20, and 10, respectively. The most critical FMs (Table 1) were directly targeted by the Time- out.
the high-priority rank, though with markedly lower RPN values. Four new highest-ranked FMs (Table 2) emerged after the intervention; all had previously been scored low (not within the top 20) and were unrelated to the Time-out intervention.
The absolute ranking of the highest RPNs in Year 3 remained consistent with previous analyses, confirming the reproducibility of the training-based assessment and the effectiveness of corrective measures in reducing previously high-risk items. Conclusion: Structured FMEA-based training effectively fosters a proactive safety culture among residents. The implementation of a multidisciplinary Time-out checklist, developed from resident analyses, significantly reduced high-priority risks in CT simulation. This model supports the integration of risk management into clinical education and continuous process improvement. References: 1. https://doi.org/10.3390/ijerph190737722. https://doi.o rg/10.1118/1.4947547 Keywords: FMEA training, CT safety, postgraduate course The ON-COME Project: A Paediatric Oncology Network for Communication on the Mind–Body– Environment relationship in Radiotherapy Care Elisa Marconi 1 , Livia Sani 2 , Valentina Massaroni 2 , Luca Liberati 1 , Angelica Marfoli 1 , Saverio Gravina 3 , Teresa Arci 3 , Elisa Meldolesi 4 , Silvia Mariani 4 , Fatjona Kraja 5 , Andrea De Salvo 6 , Giulia Albino 6 , Angela Mastronuzzi 6 , Antonio Ruggiero 7 , Giulia Zucchetti 8 , Maria Antonietta Gambacorta 9 , Silvia Chiesa 4 , Daniela Pia Rosaria Chieffo 2 1 Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. 2 Department of Life Sciences and Public Health, Catholic University of Sacred Heart, Rome, Italy. 3 Grant Office, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. 4 Radiation Oncology Unit, Diagnostic Imaging and Radiation Oncology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. 5 Oncology Department, University Hospital Center Mother Teresa, Tirana, Albania. 6 Department of Onco- hematology, Gene and Cell Therapy, Ospedale Digital Poster 4968
After its introduction, mean RPN decreased to 4.5 ± 2.6 (mean reduction 65%, p < 0.01), with all but one FM showing improvement. Only one FM remained within
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