S1518
Interdisciplinary - Quality assurance and risk management
ESTRO 2026
Laguna, Rocío Sanhueza, Francy Rivera, Pablo González Servicio de Radioterapia Avanzada, Fundación Arturo López Pérez, Santiago, Chile Purpose/Objective: With few documented Incident Learning System (ILS) experiences from Latin America, our aim is to describe the design, implementation and technological evolution (2023–2025) of a novel ILS at a high- complexity radiation oncology center in Chile. Our center manages approx. 2500 treatments annually within a multi-vendor environment (5 LINACs, 1 HDR brachytherapy unit). We detail the transition from a manual data-entry process to a dynamic, cloud-based workflow, designed to leverage descriptive statistics for robust data analysis and support continuous quality improvement initiatives focused on processes. Material/Methods: An ILS was developed based on SAFRON and SEVRRA frameworks. The classification system is structured into four phases (Non-clinical, Pre-treatment, Treatment, Post-treatment), each divided into stages and sub-stages. Initially (2023), institutional incident report PDFs were manually downloaded, analyzed, and categorized by a dedicated "Quality Leaders" group. In 2025, a new workflow was implemented, migrating consolidated data to a Google Sheets database. This database feeds dynamic, interactive dashboards (built in Google Looker Studio® and replicated in Power BI®) for real-time visualization and trend analysis. Results: Between 2023 and 2025, 155 events were reported and analyzed (see Table1), with reports trending upward annually (43 in 2023, 52 in 2024, 60 in 2025), indicating a strengthening safety culture. The migration to the Google-based platform significantly improved the granularity of event categorization (e.g., administrative, near miss, preventable/non- preventable adverse event and sentinel) and enabled individualized case analysis. The interactive dashboard (Figure 1), allows dynamic visualization of reports by professional group, workflow phase/stage/sub-stage, and temporality. Key trends have been identified: 1) over 43% of all events originate in the Pre-treatment phase; 2) 'near miss' is the most frequent event category, accounting for 47% (73/155) of reports; and 3) dosimetrists currently have the highest reporting rate. A deeper analysis using the dashboard pinpoints the most frequent process "stages" (Etapas) for reports, identifying 'Scheduling and Prior Communications' (stage 1.4) and 'Planning Image Acquisition' (stage 2.2) as the primary targets for future interventions.
Figure 1
Figure 2 Conclusion: The one single fraction trial has proven to be clinically feasible with all patients completing the whole workflow in one day. Planning, QA and tracking data of the first 13 patients showed satisfactory results, including the confirmation that the applied margins under tracking with CK are safe. Keywords: One-day procedure, SBRT prostate, CK tracking
Digital Poster Highlight 2422
Development and Implementation of a Modern, Cloud-Based Incident Learning System (ILS) in a Latin American Radiation Oncology Center Matías Pino Verdugo, Marcelo Ribeiro Picioli, Hernan Letelier, Gabriel Angulo, Filippo Marangoni, Raúl
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