Session Invited Program IM/TH- Formal Quality Management Tools

Improving Patient Safety in Radiation Therapy Using Prospective Hazard Analysis

Description

Prospective Hazard Analysis (PHA) plays an increasingly central role in modern radiation therapy, spurred by the formation and publication of AAPM Task Group 100 in 2016 [Huq MedPhys 2016]. TG 100 identified that many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limited QM resources efficiently to produce maximum safety and quality of patient care. TG 100 also proposed a framework for performing a PHA by applying failure mode and effects analysis (FMEA) and fault tree analysis. A 2025 systematic review of PHA in radiation therapy [Hindmarsh MedPhys 2025] assessed the PHA literature, evaluating which techniques and technologies have been assessed, how they have been assessed, and what can be learned. The review found that the patient journey was the most analyzed process, physicists were more involved in studies than other disciplines, FMEA the most common technique, and the delivery of patient treatment was the greatest source of high-risk failure modes. Stimulated by the 2025 systematic review article, and noting 2026 will be 10 years since TG 100 was published, the goals of this symposium are to: 1.

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