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.
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