Flashcards in QA and Error Reporting Deck (11):
Define quality assurance
- 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
What is risk management?
- reducing the possibility of errors, and where errors occur, to mitigate their effect so that the loss incurred is small
Who looks after QA at a RT site?
- site manager
- radiation oncologist
- clinical lead
- charge therapist and deputy charge
- junior therapist
What should be checked in morning run up QA?
- 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
- 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
What are the steps for reporting an incident?
- 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
What time of the day do most errors occur?
What is the QA incident reporting culture?
- 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
What causes human error?
- inattention to detail
- change of protocol
- change of planning system with limited training
- lack of supervision
- poor communication
What are some types of errors?
- single patient error
- human interface complexity error
- systematic error
- procedural error
What is a single patient error?
- wrong patient
- wrong position
- wrong site
- wrong equipment/plan
- usually low impact and possibility of corrective action may be taken