TreatSafely

Improving Quality and Safety in Radiation Medicine

Interactive Workshops

Our workshops are intensive, extremely interactive, and a whole lot of fun. We cover a lot of content, but leave plenty of room for discussion.

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Minimizing Errors, Maximizing Quality - Sample Workshop Schedule

Friday

Breakfast - 7:00 - 8:00

Welcome and introduction - 8:00 - 8:15

Session 1: Human Factors - 8:15 - 9:00

  • Discuss Rasmussen's categories of human performance.
  • Look at how performance might be compromised with clinical examples.
  • Consider an alternative way to categorize human factor-related failures.
  • Discuss the Power Distance Index.

Session 2a: Incident Learning - 9:00 - 9:45

  • Introduce the concept of retrospective analysis of incidents in radiation oncology.
  • Review two approaches to incident learning: the Radiation Oncology Safety Information System (ROSIS) developed through ESTRO and the Calgary Incident Learning System (CILS) developed in Calgary, Alberta, Canada.
  • Introduce the use of Basic Cause analysis in incident learning.
  • Review and compare analysis of incidents from ROSIS and CILS.

Mid-morning coffee break - 9:45 - 10:15

Session 2b: Incident Learning - Practical Exercise - 10:15 - 11:00

  • Identify dominant human factors for each of the 5 well known incidents from the IAEA slide set.
  • Determine basic causes for each incident.

Session 3a: Preventive Measures and Practical Exercise - 11:00 - 12:30

  • Review published preventive measures and consider their relevance to the 'IAEA' incidents.

Lunch - 12:30 - 13:30

Session 3b: Process Maps and Practical Exercise - 13:30 - 14:30

  • Review process maps and trees and develop our own maps and/or trees for sub-processes encountered in a radiation medicine program.

Session 4a: Root Cause Analysis (RCA) - 14:30 - 15:15

  • Provide an overview of the context and methodology of Root Cause Analysis (RCA).
  • Review the New York incident as presented in the IAEA slide set.
  • Discuss the US VA's approach to RCA.

Afternoon Break - 15:15 - 15:45

Session 4b: Root Cause Analysis (RCA) - Practical Exercise - 15:45 - 16:45

  • Work through an example application of an RCA loosely based on the Ottawa incident.

Session 5a: Failure Modes and Effects Analysis - 16:45 - 17:30

  • Motivate the use of FMEA and provide an introduction to the application of FMEA in radiation medicine.
  • Introduce two approaches to performing an FMEA.

Conference Dinner

Saturday

Breakfast - 7:00 - 8:00

Session 5b: Failure Modes and Effects Analysis - Practical Exercise - 8:00 - 9:00

  • Perform an FMEA using the two different approaches.
  • Illustrate the dependence of the results of an FMEA on the approach used and on the individuals performing the analysis.

Session 6a: Fault Tree Analysis - 9:00 - 9:45

  • Provide an overview of the context and methodology of Fault Tree Analysis (FTA).
  • Introduce published examples of data-based and elicitation-based probabilistic Fault Trees.
  • Comment on Root Causes/Contributing Factors identified through FTA.

Mid-morning coffee break - 9:45 - 10:15

Session 6b: Fault Tree Analysis - Practical Exercise - 10:15 - 11:00

  • Develop an FTA based on a Process Map designed during Session 3.

Session 7a: Process Control - 11:00 - 12:00

  • Learn techniques of process control.

Lunch - 12:00 - 13:00

Session 7b: Process Control - Practical Exercise - 13:00 - 14:00

  • Work through several examples of control charts for routine processes and for infrequent events.

Session 8a: Quality Management - 14:00 - 14:45

  • Review definitions of some commonly used expressions in the field of Quality Management.
  • Explore the relationship between quality management and error management as they relate to dosimetry in radiation medicine.
  • Consider documentation and auditing.

Session 8b: Quality Management - Practical Exercise - 14:45 - 15:45

  • Work through the management challenge of assigning resources to quality and safety.

Wrap-Up - 15:45 - 16:00