TABLE 2.
Most frequently reported failure modes via ROILS reporting from September 2019 to August 2021
| FM # | Failure mode | Number of events | Primary QA step | Number (%) errors detected by primary QA step |
|---|---|---|---|---|
| 19 | Pregnancy status not assessed | 166 | CT Sim | 164 (98.8%) |
| 17 | Wrong target dose | 83 | Daily contour rounds | 61 (73.5%) |
| 45 | Miscommunication on treatment strategy from the physician to the rest of the team | 69 | Daily contour rounds | 63 (91.3%) |
| 5 | Incorrect or missing pathology | 68 | CT sim | 65 (95.6%) |
| 6 | Dose in plan does not match intended | 44 | Daily contour rounds | 34 (77.3%) |
| 13 | Wrong preliminary prescription (e.g., wrong energy, dose/# fx, bolus, type of image guidance) | 37 | Daily contour rounds | 30 (81.1%) |
| 43 | Incorrect field parameters | 32 | Initial plan check | 10 (31.3%) |
| 35 | Suboptimal plan | 22 | Physics review | 7 (31.8%) |
| 33 | Treatment devices omitted (such as bolus) | 21 | Initial plan check | 12 (57.1%) |
| 18 | Missing MD or dosimetry contours | 18 | Daily contour rounds | 9 (50.0%) |
| 8 | Sub‐optimal treatment plan or approach related to communication or coordination with multidisciplinary care | 17 | None* | NA* |
| 46 | Pacemaker/defibrillator patient not monitored adequately during treatment | 17 | None* | NA* |
| 31 | Incorrect laterality | 16 | Initial plan check | 14 (87.5) |
*
These failure modes were identified as “gaps” in our QA program.