600 / 879
IQS linked to Lean
Mixed Prisma / fishbone analysis:
▪
Man:
Unreliable!
▪
Material
(patient):
Tried marking the (new) isocenter >> extra marking/tattoos give more
confusion, especially in small shift
▪
Method:
Tried orange form on charts of patient with shift >> today is common use
SOP reduced “no shift applied”, wrong shift remains.
▪
Machine:
Shift entered in treatment couch control (TCSA, Theraview®)
Multi-disciplinary decision:
RO, physicists, RTT’s, management and industry involved.
Continuous Improvement: Methods
Incident Registration
Discussion