QA and Error Reporting

Question 1

Define quality assurance

Answer 1

• all procedures that ensure consistency of the medical prescription, and safe fulfillment of that prescription, as regards to the dose to the target volume, together with minimal dose to normal tissue, minimal exposure or personnel and adequate patient monitoring aimed at determining the end result of treatment

Question 2

What is risk management?

Answer 2

• reducing the possibility of errors, and where errors occur, to mitigate their effect so that the loss incurred is small

Question 3

Who looks after QA at a RT site?

Answer 3

EVERYONE

• site manager
• radiation oncologist
• physicist
• clinical lead
• charge therapist and deputy charge
• junior therapist
• SPP

Question 4

What should be checked in morning run up QA?

Answer 4

• computer start-up & program launch
• lights and CCTV
• MLC launch and self check
• linac temp and pressure
• field light size
• X & Y jaw movements
• graticule alignment
• couch shifts
• gantry, colli and floor rotation
• laser alignment
• SSD
• interlocks LMO button
• beam outputs
• beam interrupt door open
• beam on lights
• MLC in room check
• imaging OBI, XVI warmup and alignment
• patient scheduale
• new starts
• equipment for patient setup
• consumables

Question 5

What are the steps for reporting an incident?

Answer 5

• after incident stop and take note of what happened
• record on database (time, date & place)
• who was involved
• treatment details
• factors influencing error (staff shortage, time of day)
• what immediate action was tken

Question 6

What time of the day do most errors occur?

Answer 6

• 1-2pm

- 7-8pm

Question 7

What is the QA incident reporting culture?

Answer 7

• blame: the individual is identified and dealt with
• no blame: the incident is analysed and the system is held accountable
• justifiable culture: whereby the practitioner must justify their actions in the event and there can be repercussions for poor performance

Question 8

What causes human error?

Answer 8

• fatigue
• inattention to detail
• change of protocol
• change of planning system with limited training
• lack of supervision
• poor communication

Question 9

What are some types of errors?

Answer 9

• single patient error
• human interface complexity error
• systematic error
• procedural error

Question 10

What is a single patient error?

Answer 10

• wrong patient
• wrong position
• wrong site
• wrong equipment/plan
• usually low impact and possibility of corrective action may be taken

Question 11

What is the QA incident reporting culture?

Answer 11

• Blame: the individual is identified and dealt with
• No Blame: the incident is analysed and the system is held accountable
• Justifiable culture: whereby the practioner must justifty their actions in the event and there can be repercussions for poor performance