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L1 - PS - what is risk Avignon 		1
What is risk and what is making mistakes. 		1
What is risk and what is making mistakes. 		2
Delft, October 12th, 1654 		3
Danger 		4
Slide Number 5 		5
Slide Number 6 		6
Slide Number 7 		7
Slide Number 8 		8
Slide Number 9 		9
Slide Number 10 		10
Slide Number 11 		11
Slide Number 12 		12
Risk or danger? 		13
What are statistics? 		14
What are statistics? 		15
First application 		16
What is risk? 		17
Slide Number 18 		18
Slide Number 19 		19
Top 10 health technology hazards for 2013 		20
Slide Number 21 		21
Slide Number 22 		22
Slide Number 23 		23
Quizz… 		24
Slide Number 25 		25
Toulouse, Sept 21, 2001 		26
Complex systems ? 		27
Complex systems ? 		28
Complex systems need elaborate monitoring and safety 		29
Slide Number 30 		30
Paradox of automation 		31
MAINTENANCE CAN SERIOUSLY DAMAGE YOUR SYSTEM… 		32
Which aspect of maintenance is the most error prone? 		33
The Heinrich triangle 		34
Slide Number 35 		35
The lifespan of a hypothetical organisation through the production-protection space 		36
L2 - TK - Setting the scene 2016 		37
Setting the Scene 		37
Learning objectives 		38
Six major accidents will be reviewed 		39
1 – Erroneous commissioning of a linear accelerator for stereotactic treatments 		40
Inappropriate calibration 		41
Background 		42
Discovery and impact of the accident 		43
Lessons to learn 		44
References 		45
2 – Incorrect repair ofaccelerator 		46
Events: an overview 		47
A “faulty display” 		48
Events: an overview 		49
Consequences: an overview 		50
Slide Number 15 		51
The Sagittaire accelerator 		52
The electron path 		53
During the repair 		54
Lessons to learn: Radiotherapy Department 		55
Aftermath 		56
3 – Accelerator interlock failure 		57
February 27, 2001 		58
Continue… 		59
Action of the physicist 		60
Action of the physicist 		61
Vendor came in the next day 		62
Steps to initiate radiation 		63
Dose rate vs gun current 		64
Lessons in short 		65
4 – Mis-calibration of beam 		66
Erroneous calibration, Exeter, UK, 1988 		67
Slide Number 33 		68
What went wrong and how it was detected? 		69
Lessons 		70
Lessons to learn 		71
Looking around 		72
5 – In-correct use of treatment planning system 		73
North Staffordshire Royal Infirmary, 1982-1991 		74
News when detected 		75
Lessons 		76
Looker further – Calibration of TPS – Australia 		77
6 – Non-updated data route or Erroneous use of treatment planning system and oncology information system 		78
Incorrect manual parameter transfer 		79
What happened? 		80
What happened? 		81
How did it hit the patient 		82
Discovery of accident 		83
Latent threat 		84
Lessons to learn 		85
Lessons to learn 		86
Looking around 		87
“Causes” of the accidents in this lecture 		88
Slide Number 54 		89
L3 - EL - AUTOPSY OF EPINAL 		90
Autopsy of the Epinal accident 		90
Slide Number 2 		91
The RT department of Epinal 		92
EPINAL 		93
19 months ? 		94
Why ? 		95
The initial report IGAS/ASN feb 2007 		96
Interruption of the treatments 		97
Group I : the 24 victims 		98
Groupe II: the « 400» with excess of dose 		99
Group III: the « 5000 » with error of calculation 		100
Summary 		101
Follow up of the patients 		102
Fees 		103
Insurance fees Sham 		104
Starting the new treatments 		105
The Trial 		106
Accident in ToulouseApril 2006- April 2007 		107
Main differences 		108
Conclusion 		109
L4 - AV - Lessons learned from radiotherapy accidentsdis 		110
Lessons learned from radiotherapy accidents 		110
Learning objectives 		111
Accidents in a healthcare 		112
Accidents in radiotherapy 		113
Potentiel for accidents in radiotherapy 		114
Why this complexity? 		115
Why this complexity? 		116
Why this complexity? 		117
Impact of complexity on errors in radiotherapy 		118
Types of errors 		119
Complexity and Automation 		120
Human complexity 		121
Human complexity 		122
Barriers 		123
Patient safety 		124
Patient safety 		125
Safety culture 		126
Safety culture 		127
Important points to remember 		128
References 		129
References 		130
L5 - TK - The genesis of an accident - 2016 		131
The Genesis of an Accident 		131
Slide Number 2 		132
Slide Number 3 		133
Radiotherapy process starts 		134
Modified plan is created 		135
Just occasionally??? 		136
Next step 		137
Continue 		138
Slide Number 9 		139
Slide Number 10 		140
Slide Number 11 		141
St. Vincent’s Hospital, U.S.A. (2005) 		142
Treatments continues with the altered/new plan 		143
Treatment performed with the new plan 		144
Discovery 		145
Explanation of the erroneous dose 		146
Slide Number 17 		147
Slide Number 18 		148
Slide Number 19 		149
Slide Number 20 		150
Slide Number 21 		151
Slide Number 22 		152
Patient informed 		153
From the files of DOH - NYC 		154
DOH files cont… 25 March 2005 		155
DOH files cont .. 19 April 2005 		156
Varian’s Response 		157
Excerpt from a Varian letter to all customers 		158
Lessons to learn 		159
Slide Number 30 		160
Slide Number 31 		161
Slide Number 32 		162
Questions 		163
Jan 2010 		164
Energy and Commerce - Subcommittee on Health held a hearing entitled "Medical Radiation: An Overview of the Issues" on Friday, February 26, 2010 		165
Mr Park’s Testimony Pt 1 		166
References 		167
Thanks for listening 		168
Slide Number 39 		169
Next session 		170
Slide Number 41 		171
Slide Number 42 		172
Do Accidents Still Happens? 		173
Aftermath 		174
L7 - PS - Why reporting incidents 		175
Why reporting incidents ? 		175
Quality & safety management 		176
Heinrich Triangle 		177
Heinrich investigation 		178
Heinrich investigation 		179
Heinrich investigation 		180
violation 		181
Heinrich Triangle 		182
Causes ? 		183
One example (Brindisi) 		184
Slide Number 11 		185
Slide Number 12 		186
Slide Number 13 		187
violations 		188
Education and training 		189
L8 - AV - Incident reportingdis 		190
Incident reporting 		190
Learning objectives 		191
Incident reporting systems 		192
Terms and definitions 		193
Incident reporting systems 		194
Incident reporting and LEARNING systems 		195
Incident reporting and learning systems (IRLS) 		196
1. Identifying the event 		197
2. Reporting the event 		198
3. Investigating the event 		199
3. Investigating the event 		200
4. Causal analysis 		201
4. Causal analysis 		202
5. Corrective actions 		203
6. Learning 		204
6. Learning 		205
Prerequisites of IRLS 		206
Prerequisites of IRLS 		207
Prerequisites of IRLS 		208
Prerequisites of IRLS 		209
Prerequisites of IRLS 		210
Prerequisites of IRLS 		211
Prerequisites of IRLS 		212
Types of IRLS 		213
Internal versus external systems 		214
Compulsory versus voluntary 		215
Specialized versus institutional 		216
Incident reporting and learning systems 		217
Slide Number 29 		218
Safron 		219
Important points to remember 		220
REferences 		221
REferences 		222
L9 - EL - communication to the media 		223
Slide Number 1 		223
Summary 		224
19 months ? 		225
Main differences 		226
Slide Number 5 		227
4 families of risk factors 		228
Slide Number 7 		229
Slide Number 8 		230
Slide Number 9 		231
Slide Number 10 		232
Roles and responsibilities 		233
What’s a crisis ? An unexpected event that may damage your organization reputation (or more…) 		234
Before a crisis 		235
During: ACTION 		236
AFTER 		237
Which event to communicate on? 		238
Slide Number 17 		239
Why getting the precursor events ? 		240
But consequences are very different !!!!!! 		241
Lille 		242
When accident is known: 		243
Slide Number 22 		244
Not to get it again (the crisis): 		245
Conclusion 		246
L10 - PD - ESTRO-Taxonomy2016 		247
Slide Number 1 		247
Slide Number 2 		248
Slide Number 3 		249
Slide Number 4 		250
Slide Number 5 		251
Slide Number 6 		252
Slide Number 7 		253
Slide Number 8 		254
Slide Number 9 		255
Slide Number 10 		256
Slide Number 11 		257
Slide Number 12 		258
Slide Number 13 		259
Slide Number 14 		260
Slide Number 15 		261
Slide Number 16 		262
Slide Number 17 		263
Slide Number 18 		264
Slide Number 19 		265
Slide Number 20 		266
Slide Number 21 		267
Slide Number 22 		268
Slide Number 23 		269
Slide Number 24 		270
Slide Number 25 		271
Slide Number 26 		272
Slide Number 27 		273
TG 100’s Process Tree 		274
Ford’s Process Map 		275
Slide Number 30 		276
Slide Number 31 		277
Slide Number 32 		278
Slide Number 33 		279
Slide Number 34 		280
Slide Number 35 		281
Slide Number 36 		282
Slide Number 37 		283
Slide Number 38 		284
Slide Number 39 		285
Slide Number 40 		286
Slide Number 41 		287
Slide Number 42 		288
Slide Number 43 		289
Slide Number 44 		290
Slide Number 45 		291
Slide Number 46 		292
Slide Number 47 		293
Slide Number 48 		294
Slide Number 49 		295
Slide Number 50 		296
Slide Number 51 		297
Slide Number 52 		298
Slide Number 53 		299
Slide Number 54 		300
Slide Number 55 		301
Slide Number 56 		302
Slide Number 57 		303
Slide Number 58 		304
L11 - PR - sundayPrisma and PRISMA-rt 		305
Prisma model & PRISMA-RT 		305
Slide Number 2 		306
(part 1) PRISMA in MAASTRO 		307
What do we want from the reports? 		308
PRISMA - model 		309
PRISMA-model 		310
Advantages of the PRISMA-model 		311
Slide Number 8 		312
patient data exchange 		313
classifications codes of rootcauses 		314
Slide Number 11 		315
management actions 		316
Action / Classification Matrix 		317
example of data analyse 		318
Slide Number 15 		319
Slide Number 16 		320
deviation between location of treatment 		321
Slide Number 18 		322
who report over who? 		323
trends in H/T/O 		324
Slide Number 21 		325
reporting committee 		326
reporting committee 		327
Conclusions 		328
(part 2) PRISMA explanation 		329
Humans in complex situation 		330
Error is Inevitable Because of Human Limitations 		331
(part 3): PRISMA-explanation 		332
Slide Number 29 		333
Slide Number 30 		334
Slide Number 31 		335
Slide Number 32 		336
Contextvariable MAASTRO 		337
PRISMA manual 		338
(part 3) PRISMA –rt collaboration 		339
Advantages of a national system 		340
association between of 17 Dutch radiotherapy departments 		341
1. content of the local part of database 		342
Slide Number 39 		343
Slide Number 40 		344
Slide Number 41 		345
2. content of the benchmark 		346
Slide Number 43 		347
example: Benchmark information used in a department 		348
Slide Number 45 		349
Method LIBB ( interobserver variability research) 		350
Results LIBB, 		351
Results PRISMA-RT NL 		352
Slide Number 49 		353
Futur ? 		354
Questions ??????Petra.reijnders@maastro.nl 		355
L12 - PR - sunday workshop PRISMA 		356
PRISMA workshop guide Lines 		356
Learning objectives 		357
PRISMA-tree development 		358
Slide Number 4 		359
Steps of a PRISMA analyse 		360
Stopping rules 		361
Slide Number 7 		362
Group exercise (1 hour) 		363
questions!!!! 		364
L13 - EL - legal aspects final 		365
Slide Number 1 		365
Radiotherapy Process 		366
Slide Number 3 		367
368
Slide Number 5 		369
Slide Number 6 		370
Slide Number 7 		371
Slide Number 8 		372
Slide Number 9 		373
Notification system 		374
Notification system 		375
Notification system 		376
Notification system 		377
Slide Number 14 		378
Slide Number 15 		379
Slide Number 16 		380
Slide Number 17 		381
382
Slide Number 19 		383
Slide Number 20 		384
Slide Number 21 		385
Slide Number 22 		386
387
388
389
Slide Number 26 		390
Equipments/drugs AFSSAPS/ANSM 		391
Slide Number 28 		392
Outside of France 		393
UK recommendations 		394
Slide Number 31 		395
Conclusion n°4 		396
Conclusion n°6 		397
Slide Number 34 		398
L14 - PD - ESTRO-Ethics2016 		399
Slide Number 1 		399
Slide Number 2 		400
Ethics for Radiation Medicine Professionals 		401
Ethics for Radiation Medicine Professionals 		402
Slide Number 5 		403
Slide Number 6 		404
Slide Number 7 		405
Slide Number 8 		406
Slide Number 9 		407
Slide Number 10 		408
Slide Number 11 		409
Slide Number 12 		410
Slide Number 13 		411
Slide Number 14 		412
Slide Number 15 		413
Slide Number 16 		414
Slide Number 17 		415
Slide Number 18 		416
Slide Number 19 		417
Slide Number 20 		418
Slide Number 21 		419
Slide Number 22 		420
Slide Number 23 		421
Slide Number 24 		422
Slide Number 25 		423
Slide Number 26 		424
Slide Number 27 		425
Slide Number 28 		426
Slide Number 29 		427
Slide Number 30 		428
Slide Number 31 		429
Slide Number 32 		430
Slide Number 33 		431
Slide Number 34 		432
Slide Number 35 		433
Slide Number 36 		434
Slide Number 37 		435
Slide Number 38 		436
Slide Number 39 		437
Slide Number 40 		438
Slide Number 41 		439
Slide Number 42 		440
Slide Number 43 		441
Slide Number 44 		442
Slide Number 45 		443
Slide Number 46 		444
Slide Number 47 		445
Slide Number 48 		446
Slide Number 49 		447
Slide Number 50 		448
Slide Number 51 		449
Slide Number 52 		450
Slide Number 53 		451
Slide Number 54 		452
Slide Number 55 		453
Slide Number 56 		454
Slide Number 57 		455
Slide Number 58 		456
L15 - PS - Just culture Avignon 		457
A Just culture 		457
So, what are Human Factors? 		458
So, what are Human Factors? 		459
Blame Culture 		460
Blame Culture 		461
Problems with a blame culture 		462
Problems with a blame culture 		463
Problems with a blame culture 		464
tchernobyl 		465
Problems with a blame culture 		466
Problems with a blame culture 		467
Problems with a blame culture 		468
No-Blame Culture 		469
Safety rules on an air carrier 		470
Safety rules on an air carrier 		471
Problems with a No-blame culture 		472
A ‘Just’ Culture 		473
Just Culture 		474
Why we do need a “Just” Culture? 		475
Why we do need a “Just” Culture? 		476
A problem in 1996 		477
A plane crash a day 		478
Problems with a Just Culture 		479
Just Culture Code of Practice (1) 		480
Just Culture Code of Practice (2) 		481
Just Culture Code of Practice (3) 		482
tchernobyl 		483
Two sides of a same coin 		484
Toulouse, Sept 21, 2001 		485
Slide Number 30 		486
Problem 1 		487
Problem 2 		488
Problem 3 		489
Problem 4 		490
Two key operational realities a just culture policy needs to accommodate 		491
The Operational Reality : Professional dilemmas 		492
Key professional dilemmas 		493
The Operational Reality : Routine Non-Compliance 		494
Organisational Learning 		495
Absence of Just Culture can cause 		496
Learning from Errors & Incidents 		497
L16 - PD - ESTRO-Near Miss2016 		498
Slide Number 1 		498
Slide Number 2 		499
Slide Number 3 		500
Slide Number 4 		501
Slide Number 5 		502
Slide Number 6 		503
Slide Number 7 		504
Slide Number 8 		505
Slide Number 9 		506
Slide Number 10 		507
Slide Number 11 		508
Slide Number 12 		509
Slide Number 13 		510
Slide Number 14 		511
Slide Number 15 		512
Slide Number 16 		513
Slide Number 17 		514
Slide Number 18 		515
Slide Number 19 		516
Slide Number 20 		517
Slide Number 21 		518
Slide Number 22 		519
Slide Number 23 		520
Slide Number 24 		521
Slide Number 25 		522
Slide Number 26 		523
Slide Number 27 		524
Slide Number 28 		525
Slide Number 29 		526
Slide Number 30 		527
Slide Number 31 		528
Slide Number 32 		529
Slide Number 33 		530
Slide Number 34 		531
Slide Number 35 		532
Slide Number 36 		533
Slide Number 37 		534
Slide Number 38 		535
Slide Number 39 		536
Slide Number 40 		537
Slide Number 41 		538
Slide Number 42 		539
Slide Number 43 		540
Slide Number 44 		541
Slide Number 45 		542
Slide Number 46 		543
Slide Number 47 		544
Slide Number 48 		545
Slide Number 49 		546
IAEA’s e-learning program 		547
Slide Number 51 		548
L17 - AV - Safety in the RT departmentdis 		549
Safety in the RT department 		549
Learning objectives 		550
Human complexity 		551
Effectiveness of different approaches in preventing errors 		552
Forcing functions 		553
Forcing functions 		554
Effectiveness of different approaches in preventing errors 		555
Automation and computerization 		556
Automation and computerization 		557
Slide Number 10 		558
Slide Number 11 		559
Effectiveness of different approaches in preventing errors 		560
Simplification and standardisation 		561
Effectiveness of different approaches in preventing errors 		562
Checklist 		563
Slide Number 16 		564
Workflow management systems 		565
Open source solution – iTP 		566
Double checks 		567
Effectiveness of different approaches in preventing errors 		568
Slide Number 21 		569
Effectiveness of different approaches in preventing errors 		570
Training 		571
Points to remember 		572
References 		573
L18 - PR - monday HFMEA 		574
Health care Failure Mode and Effects Analysis (HFMEA), a prospective method 		574
content of presentation 		575
Retrospective 		576
Proactive 		577
Slide Number 5 		578
Learning Objectives 		579
prospective risk models 		580
overview proactive risk models 		581
Rough deviation of the models 		582
COSO/ERM 		583
Six Sigma/Lean 		584
Food and drink industry: HACCP 		585
HAZOP / HAZAN 		586
What is (H)FMEA? 		587
History of FMEA 		588
(H)FMEA 		589
HFMEA 		590
HFMEA-organization 		591
Process prescription as fundament for HFMEA 		592
Slide Number 20 		593
Process prescription f.e. 		594
tips for process description 		595
What is a Failure Mode? 		596
6 M’s to define the failure modes 		597
HFMEA Procedure (1) 		598
HFMEA Procedure (2) 		599
Flow of the Analysis 		600
Risk Priority Number (RPN) 		601
Rating Scales 		602
Scaling severity and probability (for example) 		603
checklist 		604
HFMEA form 		605
After Calculation RPN 		606
conclusions 		607
Are there no incidents after doing a HFMEA? 		608
MAASTRO’s experience 		609
research within MAASTRO 		610
References 		611
Tips and tricks 		612
tip 		613
HFMEA and the RCA Process 		614
questions!!!! 		615
simple exercise 		616
sub processes 		617
2. taking breakfast 		618
2.3 break an egg 		619
Slide Number 47 		620
HFMEA analyses MAASTRO 		621
Relationship between prospective and retrospective risk analyses 		622
questions!!!! 		623
L19 - PR - monday workshop HFMEA 		624
workshop HFMEA 		624
Learning Objectives 		625
(H)FMEA 		626
method 		627
HFMEA Organisation (1) 		628
(2) 		629
Division of roles between membres and Time involved 		630
Exercise 		631
examples of process 		632
define process/subprocesses and select a piece of a subprocess 		633
tips for process description 		634
Slide Number 12 		635
questions!!!! 		636
L20 - PR - monday combining retrospective and prospective 		637
Pracitical example how to use Patient Safetytools during transitioncombining prospective and retrospective risk management 		637
MAASTRO 		638
Facts - Staff 		639
Facts- Treatments 		640
content of the presentation 		641
Risk Rt and transitions 		642
Impact transitions 		643
tools used 		644
1: PRISMA - model 		645
Varian equipment 		646
Bilocation Venlo 		647
Histogram of the classification code 		648
tools used 		649
Varian equipment 		650
Bilocation Venlo 		651
Slide Number 16 		652
Improve bord 		653
tools used 		654
New items for selective treatment check 		655
Culture & communication 		656
tools used 		657
2013 visitation of our member of the board 		658
tools used 		659
RTT with area of interest Patient safety 		660
Slide Number 25 		661
Publication national RTT journal 		662
ERM/enterprise risk management 		663
Risk area’s 		664
Slide Number 29 		665
L21 - AV - Communication in safetydis 		666
Communication in safety 		666
Learning objectives 		667
Communication in safety 		668
Communication to prevent errors 		669
Slide Number 5 		670
Slide Number 6 		671
Checklist in surgery? 		672
Slide Number 8 		673
Communication to prevent errors 		674
Communication within the organization/with the patients 		675
Post incident management 		676
Who are the victims of an error? 		677
What the patient/family wants… 		678
What the patient/family wants… 		679
Communication with victims – Who, when and what 		680
Communication with victims – Who, when and what 		681
Communication with victims – Who, when and what 		682
Communication with victims – Who, when and what 		683
Communicating with the second victims 		684
Third victim… 		685
Important points to remember 		686
References 		687
L22 - PD - ESTRO-Human Factors 2016 		688
Slide Number 1 		688
Slide Number 2 		689
Slide Number 3 		690
Slide Number 4 		691
Slide Number 5 		692
Skill-based performance 		693
Rule-based performance 		694
Knowledge-based performance 		695
Performance categories 		696
Where does competency fit in? 		697
Slide Number 11 		698
How might our performance be sub-optimal? 		699
Error – Expanded definition 		700
Skill – Based Errors 		701
Skill – Based Errors 		702
Skill – Based Errors 		703
Skill – Based Errors 		704
Rule – Based Issues 		705
Rule – Based Issues 		706
Knowledge – Based Mistakes 		707
Knowledge – Based Mistakes 		708
Violations 		709
Violations 		710
Violations 		711
Comparison of Error Types 		712
Slide Number 26 		713
Mapping Performance Levels to Error Types 		714
Is There Another Way of Classifying Errors? 		715
Mapping Error Categories to Error Types 		716
Slide Number 30 		717
Performance categories 		718
Violations – Preventive Measures 		719
Knowledge–Preventive Measures 		720
Rules – Preventive Measures 		721
Skills – Preventive Measures 		722
Time-outs 		723
Time-outs 		724
No Interruption Zone (NIZ) 		725
No Interruption Zone 		726
No Interruption Zone 		727
No Interruption Zone 		728
First Date Rule 		729
First Date Rule 		730
Intuition 		731
Power Distance Index 		732
Power Distance Index 		733
Power Distance Index 		734
Power Distance Index 		735
Power Distance Index 		736
Slide Number 50 		737
Slide Number 51 		738
Slide Number 52 		739
Slide Number 53 		740
Slide Number 54 		741
Slide Number 55 		742
Slide Number 56 		743
Slide Number 57 		744
Slide Number 58 		745
L23 - Role play 		746
Role play 		746
A voluntary 		747
A voluntary 		748
A voluntary 		749
A voluntary 		750
A voluntary 		751
A voluntary 		752
A voluntary 		753
The scenario 		754
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