S1508
Interdisciplinary - Quality assurance and risk management
ESTRO 2026
Digital Poster 1527 Enhancing patient safety in SGRT and DIBH through combined prospective and retrospective risk analysis Severine Cucchiaro, Manon Baiwir, Michael Noel, François Lallemand Radiotherapy, CHU Liege, Liege, Belgium Purpose/Objective: The integration of Surface-Guided Radiation Therapy (SGRT) with Deep Inspiration Breath Hold (DIBH) provides significant clinical advantages, including improved treatment accuracy, better protection of organs of interest, enhanced setup reproducibility, and increased patient comfort. However, these techniques also introduce new technical and organizational risks. The aim of this study is to combine prospective (FMEA) and retrospective (incident reporting) risk analyses to identify process vulnerabilities and improve patient safety. Material/Methods: A Failure Mode and Effects Analysis (FMEA) was conducted across the radiotherapy workflow, including patient selection, respiratory coaching, simulation, patient setup, verification, and treatment delivery using SGRT/DIBH. In parallel, all adverse events reported over a 24-month period were collected and classified using the Eindhoven model. The findings of both assessments were compared step-by-step, considering the frequency and severity of risks, as well as the effectiveness of existing safety
Conclusion: Collected data confirm the essential role of the medical Physicists in developing and implementing advanced planning and dosimetry strategies necessary to prevent CIED malfunction and ensure patient safety. Moreover, rigorous management focused on minimizing beam exposure (primary or neutron- producing) substantially reduces serious malfunction rates. The reported flowcharts are intended to guide medical physicists in their daily clinical practice. References: [1] Falco D, et al. in vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience. Phys Med. 2022; 94:94-101.[2] Peet SC, et al. Measuring dose from radiotherapy treatments in the vicinity of a cardiac pacemaker. Phys Med. 2016; 32(12):1529-1536.[3] Stick LB, Lægdsmand PMT, Bjerre HL, et al. Spot-scanning proton therapy for targets with adjacent cardiac implantable electronic devices - Strategies for breast and head & neck cancer. Phys Imaging Radiat Oncol. 2022; 21:66-71.[4] Aslian H, et al. Multicenter dosimetry study to evaluate the imaging dose from Elekta XVI and Varian OBI kV-CBCT systems to CIEDs. Phys Med. 2018; 55:40-46. Keywords: CIEDs-flowchart-statistics
barriers. Results:
The FMEA identified 11 key process steps and 24 potential failure modes. Of these, 11 had low criticality, 8 moderate, and 5 high. Over the 24-month period, 52 incident reports were collected. The cross- analysis revealed several divergences: certain human errors and organizational weaknesses identified retrospectively were not fully anticipated in the prospective FMEA, especially during coaching preparation (patient recruitment/assessment), simulation (surface acquisition), and treatment delivery (system bypass). Conversely, some risks identified by the FMEA such as incorrect immobilization device selection or patient-surface mismatch were not associated with any reported incidents, demonstrating the effectiveness of existing safeguards. Based on these findings, several corrective measures were prioritized, including enhanced training for Radiation Therapists (RTTs), development of patient-oriented educational materials (brochures and videos), and improved documentation through standardized procedures.
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