S1533
Interdisciplinary - Quality assurance and risk management
ESTRO 2026
Conclusion: STPA was successfully used to assess real-time adaptive treatment on a helical tomotherapy platform, providing insight into how the system could become unsafe throughout the patient journey. While focused on the helical tomotherapy platform and real-time adaptive radiation therapy, this study offers a transferable example of STPA application, from analysis initialization to mitigation, that can serve as an example for future safety assessments in radiation therapy. References: 1. M. S. Huq et al., Med. Phys. 43, 4209–4262 (2016).2. J. Hindmarsh, S. Dieterich, J. Booth, P. Keall, Med. Phys. 52, e18110 (2025).3. L. M. Wong, T. Pawlicki, J. Appl. Clin. Med. Phys. 26, e14623 (2025).4. L. M. Wong, T. Pawlicki, J. Appl. Clin. Med. Phys. 26, e14622 (2025).5. N. G. Leveson, J. P. Thomas, STPA Handbook (MIT Press, Cambridge, UNITED STATES, 2018; https://psas.scripts.mit.edu/home/get_file.php?name= STPA_handbook.pdf).6. G.-P. Chen et al., Pract. Radiat. Oncol. 11, e486–e495 (2021). Keywords: Risk analysis, tomotherapy, real-time adaptive Digital Poster 3755 FMEA TOOL TO ANALYSE THE BRACHYTHERAPY PROCESS Claudio Pobbiati 1,2 , Andrea Vavassori 1 , Roberto Corea 1 , Luca Casucci 2 , Francesca Pavan 3 , Michela Onza 1 , Rosa Luraschi 4 , Davide Alio 4 , Stefano Durante 1 , Andrea Noe Guido 1 , Guglielmo Gatto 1 , Massimo Sarra Fiore 1,2 , Federica Cattani 4 , Barbara Alicja Jereczek Fossa 1,5 1 Radiotherapy Division, European Institute of Oncology, IRCCS, Milan, Italy. 2 Bachelor's degree programme in Imaging and Radiotherapy Techniques, University of Milan, Milan, Italy. 3 Quality, Accreditation, and Clinical Risk Service, European Institute of Oncology, IRCCS, Milan, Italy. 4 Medical Physics Unit, European Institute of Oncology, IRCCS, Milan, Italy.
Results: A control structure diagram encompassing the entire patient journey was developed (Figure 2) consisting of 12 sub-systems and 21 control actions. The control actions led to 108 unsafe control actions and 595 causal scenarios. Following prioritisation based on novelty, uniqueness to real-time tracking or difficulty in mitigation, 61 causal scenarios were selected for further analysis and the development of mitigation strategies based on the hierarchy of controls. While the focus of the analysis was delivery of real-time adaptive radiotherapy, upstream decision-making during consultation, contouring and planning were recognised as having influence on the quality and safety of adaptive treatment delivery. Actions identified from the analysis for further work included the development of better reference documentation, the systematic testing of tracking parameters, guidance around setting and documenting tracking parameters, and investigation into methods of treatment related feedback.
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