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Example: patient switched with another patient, wrong treatment administered
Value for the patient: right treatment, patient safety!!
PATIENTS
EXCHANGED
Continuous Improvement
Methods
Incident Registration Discussion
Fishbone analysis in Radiotherapy
Didn’t check name
Didn’t check DOB
Poor hearing
Same treatment area
No visual recognition
No SOP
No interlock /
check patient
No unique name
No independant
check a priori; name
Many patients
No link
patient/treatment
Imaging analysed
after treatment
Override for Table
interlock
No table interlock
Unable to respond
= staff
= patient