TABLE III.

Mitigation strategies for ART processes with critical failures.

	Failure	QC strategy	Prototypes and commercial tools
(1)	Isocenter documentation	Automated isocenter capture, checklists, monitoring trends in daily patient shifts
(2)	Miscommunication of planning directives and failure to properly account for dose accumulation	Well-defined protocols, stable clinical workflow, staff training, integrated record management, electronic physician order, and whiteboard systems	Santanam (Ref. 8), Mallalieu (Ref. 9)
(3)	Poor dataset fusion	Automated fusion tools, specialty training for onsite staff
(4)	Incorrect target/structure delineation and construction	Automated contour integrity verification software	ImSimQAcontour, StructSure (not specifically designed for ART)
(5)	Poor plan optimization and or incorrect dose computation	Automated software verifying:	RadCalc (LifeLine Software), IMSure (Standard Imaging), muCheck (Oncology Data Systems Imaging), Sun (Ref. 16), Xing (Ref. 24), Yang (Ref. 12)
		• dose computation
		• leaf sequencing
		• plan integrity
(6)	Poor plan review	Automated comparisons between planning goals and achieved goals, decision support software	Zhu (Ref. 13), Moore (Ref. 14)
(7)	Incorrect interpretation of plan data for treatment delivery	Independent verification software comparing data indicated by the planning to data read by the delivery system	QAPV (IHE-RO) (Ref. 15)
(8)	Failures in treatment parameter setup on treatment machine	Simulated delivery, pretreatment (running gantry rotations and MLC patterns without dose output)	Sun (Ref. 16), QUASAR™ Automated Delivery QA Software (Modus Medical)
		Retrospective MLC QA, post-treatment
(9)	Failures occurring during treatment delivery	Transmission detectors	In vivo EPID dosimetry, DAVID harp chamber, MatriXXEvolution, investigational transmission detectors [Islam (Ref. 19), Goulet (Ref. 20), Wong (Ref. 21)]
		Real-time MLC/gantry monitoring	Jiang (Ref. 22)