| |
|
Level 3 |
|
Level 4 |
|
| |
Parameters |
Numbers |
(%) |
Numbers |
(%) |
| Causes of incident |
Violation/skip procedure or policy |
29 |
-59% |
49 |
-45% |
| Incomplete knowledge/skill |
8 |
-16% |
2 |
-2% |
| Miscommunication |
6 |
-12% |
18 |
-17% |
| Manual misentry/operation error |
4 |
-8% |
39 |
-36% |
| Work environment |
1 |
-2% |
1 |
-1% |
| Incorrect supervision |
1 |
-2% |
0 |
- |
| Staff experiences |
≥5 years |
22 |
-45% |
66 |
-61% |
| <5 years |
27 |
-55% |
43 |
-39% |
| Caused by |
RO |
36 |
-74% |
33 |
-30% |
| MP |
0 |
- |
39 |
-36% |
| RT |
11 |
-22% |
34 |
-31% |
| RO/MP |
2 |
-4% |
1 |
-1% |
| RT/MP |
0 |
- |
2 |
-2% |
| Detected by |
Weekly review session |
31 |
-63% |
8 |
-7% |
| RO |
2 |
-4% |
8 |
-7% |
| MP |
0 |
- |
19 |
-17% |
| RT |
13 |
-27% |
74 |
-68% |
| Nurse |
1 |
-2% |
0 |
- |
| MP/RT |
2 |
-4% |
0 |
- |
| Phase of occurrence |
CT-S |
0 |
- |
23 |
-21% |
| Treatment planning |
36 |
-74% |
55 |
-51% |
| Preparation |
1 |
-2% |
17 |
-16% |
| Position verification |
1 |
-2% |
6 |
-6% |
| Treatment delivery |
10 |
-20% |
1 |
-1% |
| On-treatment verification |
1 |
-2% |
7 |
-6% |
| Phase of detection |
Treatment planning |
0 |
- |
1 |
-1% |
| Preparation |
1 |
-2% |
41 |
-38% |
| Position verification |
0 |
- |
27 |
-25% |
| Treatment delivery |
11 |
-22% |
17 |
-16% |
| On-treatment verification |
36 |
-74% |
16 |
-15% |
| Other |
1 |
-2% |
7 |
-6% |
