Incident Learning Systems
What member of the radiation oncology team discovers the most radiation events?
Who is the radiation therapist
What is a process map?
What is the steps of a process arranged in order. Shows the flow of information and displays relationships between steps
In what year did the New York Times articles come out focusing on the lack of safety in Radiation Oncology?
What was 2010
What QI program detects the number of deviations/defects in a large dataset and aims for 99.9996% detect free
Six Sigma
Name 3 medical devices
what are: cardiac defibrillator, neurostimulator, pacemaker, insulin pump, glucose pump, shunt, LVAD, infusion pump, leaf monitor
During what phase are most radiation events detected?
What is treatment
What is a near event?
What is an occurrence that, if not have been detected or corrected, would result in failure (also known as a close call, near miss, or good catch)
What regulatory agency regulates the manufacturing of linacs?
US Food and Drug (FDA)
Which of the following categories of improvement is the best for healthcare: Quick fix, initiating, conforming, deviate, or enhancing
What could happen to a medical device if it was to receive radiation?
What is malfunction or fail
What is the biggest obstacle to reporting treatment errors?
What is fear of reprimand
TG100 is a working group from what organization?
AAPM
What quality check takes place before beam-on to ensure patient identification, site, and imaging have been checked?
What is a time out or procedural pause
The lean QI program helps eliminate waste. Name an example in Radiation Oncology of skills waste
what is underutilizing staff to their capabilities
Why might a medical device be requested in a topogram scan?
What is to check distance from treatment site and potential dose it receives
Name 4 qualities of a good incident learning system
what are:
Anonymous reporting
Non punitive
Report findings in an effort to reduce likelihood of events being repeated
Publish safety related resources
Promote safety culture and continuous improvement
User friendly
Name one of the three most effective risk reduction strategies
What are: forcing functions, barriers/fail-safes, automation
What is the skills assessment the ARRT put in place for RTT's every 10 years to ensure therapists are able to meet todays requirements?
What is CQR
PDCA stands for...
What is Plan, Do, Check, Act
What medical device is used in the inpatient setting to notify nursing that reposition is needed of bed bound patients?
What is the leaf sensor
Name 5 contributing factors that could lead to a radiation event
What are: insufficient training, miscommunication, short staffing, insufficient QA, equipment failure, inattention to detail, work environment, distractions, patient factor, cluttered workspace, complex treatment, rushed
What is the swiss cheese theory?
A model that illustrates how layered defenses can prevent accidents. Each layer has weaknesses (holes) and those can align and lead to failure. The more barriers the less room for weaknesses to get through.
What are the 5 safe behaviors?
What are: pay attention to detail, communicate clearly, speak up and respond respectfully, hand off effectively, and support each other
A cause-and-effect diagram that aims to uncover gaps and quality
fishbone diagram
What are the three lines of defense to detect a medical device?
pre appointment call, MD at consult, RTT at time of sim