580 / 879
Possible solution should be sought in Machine and/or Method:
Man is never 100% safe, Material is not within circle of influence
Continuous Improvement
:
Methods
Incident Registration Discussion
Fishbone analysis
Didn’t check DOB
Poor hearing
Same treatment area
No visual recognition
Many patients
Override for Table
interlock
Unable to respond
No SOP
No interlock /
check patient
No independant
check a priori;
name
No link
patient/treatment
Imaging
analysed after
treatment
No table
interlock
Human error
Patient: not within influence
PATIENTS
EXCHANGED