C2 - mp7547 Sup 0004

Potential Failure Potential Causes of Failure Potential Effects of Rank Notes and Examples of Causes and Failures Compiled
step # Major Processes Step AVG O AVG S AVG D AVG RPN

Modes Failure Number during the analysis
6.1, 6.4 (User not familiar with

4 - Other 6. Images correctly
Incorrect interpretation modality or inadequately trained)
pretreatment interpreted (e.g.
31 of tumor or normal 1.2, 5,3 (Poor inter-disciplinary Wrong volume 6.50 7.44 8.00 387.8 1
imaging for CTV windowing for FDG
tissue. communication)
localization PET)
1 Procedure failures
2.1 – 2.3 Equipment availabilit or
effectiveness
Delineate GTV/CTV 1. >3*sigma error Wrong target volume contour leads directly to very wrong
2.5-2.6 User error Very wrong dose
(MD) and other contouring errors: dose distributions and volumes.
3.2 Desgin distributions
58 7 - RTP Anatomy structures for wrong organ, wrong 5.29 8.43 7.86 366.0 2 Low detectability assumes only review is by physicist and
3.5 – 3.6 Assessment or Very wrong volumes.
planning and site, wrong expansions MD who made error
programming
optimization Very large ‘catastrophic’ errors
6.1 Inadequate training
Inattention, lack of time, failure to
review own work
Wrong to very wrong dose affecting all patients treated on
LINAC hardware
machine (or with affected beams) until problem is found
failures/wrong dose per
1.2. Inadequate department policy Wrong dose and corrected. Everyone knows this!!! This is TG40 and
MU; MLC leaf motions
(weak physics QA process) Wrong dose distribution slightly beyond!
12 - Day N inaccurate,
209 Treatment delivered 3.2. Poor hardware design Wrong location 5.44 8.22 7.22 354.0 3
Treatment flatness/symmetry,
2.3. Poor hardware maintenance Wrong volume
energy – all the things
6.1. Poorly trained personnel
that standard physical
QA is meant to prevent.
4.3, 8. (Lack of time or attention to Previous RT treatment not taken into account in design of
detail.) treatment plan.
5.4 (Miscommunication or poor
Wrong summary of
documentation)
6 - Initial Treatment Retreatment, other treatments.
48 Planning Directive previous treatment, Other treatments not Wrong dose 5.33 8.56 7.33 332.7 4
6.1, 8.6 (User error in reconstructing
(from MD) Brachy etc documented.
previous treatment)
2.1, 2.2 (Wrong info obtained or
Information not available)
2.1 – 2.3 Equipment availabilit or Wrong dose distribution
effectiveness Wrong volumes
Delineate GTV/CTV 2. Excessive
2.5-2.6 User error
(MD) and other delineation errors
3.2 Desgin Bad drawing leads directly to geometric errors, wrong plan
59 7 - RTP Anatomy structures for resulting in <3*sigma 5.86 6.57 8.00 325.7 5
3.5 – 3.6 Assessment or or dose distribution.
planning and segmentation errors
programming
optimization
review own work
3. Margin width
protocol for PTV
1 (all) Procedure failure
construction is Wrong dose distribution
5.2-5.4 Communication failure Very common, since many depts don’t assess consistency
inconsistent with actual Wrong volumes
65 7 - RTP Anatomy PTV construction 6.1Inadequate training 7.29 5.43 7.86 316.3 6 between margins and actual setup errors. Very difficult to
distribution of patient Or
Inattention, lack of time, failure to detect when discrepancies are modest.
setup errors. Suboptimal plan
review own work
5.4. Miscommunication; Physician reviewed one of the trial plans rather than the
inattention, final plan that dosimetrist intended for MD approval. The
1.1. lack of procedure Very wrong dose; Very trial plan may have severe problems that the MD does not
1. Plan OK to go to 1.2 Inadequateprocedure wrong dose distribution notice thinking that the plan meets prescription and
137 9 - Plan Approval 3. Bad plan approved 4.89 8.00 7.89 313.3 7
treatment 1.3 Procedure not followed Very wrong volume planning criteria.
2.5 Used incorrectly
6.1 Inadequate training/orientation
Example: For some kinds of breathing motion, phase-
gating on RPM can gate at the wrong phase of the
breathing cycle (inspiration rather than expiration). If this
is not recognized, for one or more sessions, treatment of
a patient with large breathing motion can miss parts of the
tumor because the beam is on in the wrong part of the
3.2. Poorly designed software for
breathing cycle. To add to the problem, the GE 4D CT
task at hand.
Special motion Wrong dose phase calculation algorithm differs from the RPM
3.2. Poorly designed hardware.
management methods Wrong dose distribution algorithm, so a phase gate chosen on the basis of a GE
12 - Day N Set treatment 6.1. Use by inexperienced personnel
205 (e.g. gating, breath- Wrong location 6.22 6.67 7.11 310.1 8 4D study doesn’t necessarily carry over even qualitatively
Treatment parameters 2 Operator doesn’t observe counter-
hold) not applied or Wrong volume to RPM treatment!
intuitive patterns on screen (6.1. lack
incorrectly applied Example: The patient’s breathing trace for amplitude
of training, Lack of attention)
gating can drift (presumably due to overall ant/post body
motion of < 1 cm- part of body with gating block “settling”)
causing the RPM to gate on the wrong phase of the
breathing cycle.
Effect: Radiation delivered during the wrong part of the
breathing cycle with anatomy in wrong position.
Lack of dept policies/documentation Pacemaker not noticed in treatment volume for radical
Special instructions not 8.2 (Lack of time) patient.
Specify special given 8. (Lack of attention to detail.)
6 - Initial Treatment instructions, viz. 5.4 ,5.1 (Miscommunication)
Non-radiation related
46 Planning Directive pacemaker, Wrong special 5.25 8.75 6.50 305.9 9
injury
(from MD) allergies, voiding, instruction (e.g., allergy,
bowel prep, etc pacemaker) 2.2 (Wrong or inadequate info
obtained)
One needs to look at DVH and dose distribution on a slice

Not enough time/effort spent
by slice basis. But because of poor training or not
13. Evaluate plan 6.1. Inadequate training
8 - Treatment 1. Inadequate Wrong dose spending enough time to evaluate the DVH or isodose
127 (DVH, isodose, dose 8. Poor evaluation strategy 5.63 7.00 7.13 303.0 10
Planning evaluation Wrong dose distribution distribution, the result can be an inadequate evaluation of
tables, etc.) Incorrect final prescription
the plan. This may result in the effects outlined in the
effect column.
6.1 (Ignorance of available imaging Pre surgery MRI scan incorrectly selected for volume
studies) definition and patient treated.
Specify use of incorrect
5.3 (Miscommunication)
image set, Viz.; wrong
6 - Initial Treatment Specify images for 1.2, 2.6 (Ambiguous labeling of Wrong location
phase of 4D CT
40 Planning Directive target and structure image sets) Wrong volume 5.50 7.50 7.00 283.3 11
selected for planning;
(from MD) delineation, etc
wrong MR for target
2.2 (Software error)
volume delineation
8. (User error)
TPS is commissioned badly. Inadequate measurements;

Inadequate characterization of
inadequate checks etc.
delivery system in the RTPS;
5. Calculate the Incorrect absolute output;
dose to the Really bad relative dose inside beam
8 - Treatment optimization points, 1. Really bad beam Penumbra; Wrong Dose distribution.
106 4.67 7.56 7.78 282.2 12
Planning and also calc the modeling Bad leaf edge/end modeling; Wrong dose
final dose Bad outside beam modeling;
distribution Bad Buildup region modeling;
Bad Transmission factors
4-D representations 6.1. Inadequate training Wrong volumes, leading

If planning is to be based on 4-D representation (even if
(ie, multiple Inability to support 4-D 2.2. Software error or limitation to wrong dose distribution.
the 4-D is a simple inhale and exhale dataset), then wrong
78 7 - RTP Anatomy anatomical data 2.5. User error (being tricky to mimic 5.29 7.00 7.43 278.4 13
choices, limited or inexperienced use of software could
representations over support)
lead to incorrect volumes and then dose.
time)
Specify wrong motion Margins set at end exhale when they should have been
–compensated set for quiet breathing.
6.1, 8.1 (Ignorance of methods
treatment protocol. Highly dependent on how much margin is reduced when
available. Lack of forethought. Lack
specified margin size motion compensation is used
of understanding of motion impact)
Motion and inconsistent with
6 - Initial Treatment uncertainty motion management
44 Planning Directive management technique Wrong volume 6.63 6.38 6.25 277.5 14
(from MD) (includes PTV and
2.6 (Inadequate
PRV) Specified duty cycle
commissioning/acceptance testing)
and breathing phase
1.2 (inadequate procedures)
inconsistent with
margin for gating)
Manual entry: Large error Very wrong dose Very Some planning systems may not upload all treatment
1. Incorrect Tx info, 2.
1.2 Inadequate procedure wrong dose distribution parameters digitally to R&V. Error >10% is made in
10 - Plan Wrong Rx,
168 9. Prepare e-chart 1.3 Procedure not followed Very wrong location 5.44 8.89 5.56 272.9 15 manual entry of fractions or dose carried.
Preparation 3. Wrong patient/plan
6.1 Inadequate training/orientation Very wrong volume
Fusion is easy to do poorly – no quantitative result to

check. Can be wrong position, wrong orientation,
1.1-1.4 Procedure failures Max: Very wrong dose
distorted, etc. Leads to wrong geometric position, possibly
Poor /wrong fusion. 1.6 Procedure not implemented distribution and/or
Dataset registration wrong dose.
(Mispositioning, mis- 2.2 -2.4 Equipment defective volumes
57 7 - RTP Anatomy (fusion) of multiple 5.63 6.63 6.75 272.1 16 We think small registration errors are highly likely but
orientation, distortion) 2.5 User error Min Wrong dose
datasets have moderate consequences. Moderate reigstration
3.6 Inadequate programming distributions and/or
errors should be highly detectable by image review, if it is
6.1 Training failure volumes
performed carefully
Incomplete/ incorrect Important OAR not contoured and not taken into account
6.1 (Ignorance of available imaging
list of specified in design of treatment plan
Specify protocol for studies)
structures and
delineating target 5.3 (Miscommunication)
6 - Initial Treatment corresponding image
and structure (which 1.2, 4.5 (Ambiguous labeling of
41 Planning Directive sets. Wrong volume 6.22 7.67 5.56 266.4 17
structures to contour image sets)
(from MD)
and CTV delineation 1.1 (Lack of eplicit protocol)
CTV maybe incorrectly
guidelines) 8. (User error)
contoured
Suppose Physician wants 95% vol. to be covered by 50

Gy. Step 1: Optimizer gives 90% vol. is covered by 50
Gy.
Step 2: Physician can accept this and prescribe such that
the 90% vol. receives the Px dose. This is OK as long as
he understands what he is doing.
2. Enter prescription 2. Incorrect dose
8 - Treatment Step 3: Physician really wants 95% vol. to be covered by
94 + planning prescription and dose A. 8. Human error by the RO Very wrong dose 5.22 7.56 6.44 264.9 18
Planning 50 Gy. For this to happen, he will have to choose an
constraints limit constraints
appropriate isodose line such that 95% vol. receives the
Px dose. He will have to do this because the optimizer
returned with a value of 90% vol. covered by the Px dose.
In this case the max dose to the target will be higher
which is something the physician did not want.
For a given disease site departmental guidelines do not

exist on how far above and below the target one should
8 - Treatment 1. Specify ROI for 3. Inconsistent length 1.2Lack of consistent guidelines scan the patient. Also, guidelines do not exist for the
85 Wrong dose distribution 6.00 6.56 6.67 264.6 19
Planning optimization process (sup/inf) of ROI resulting in human error appropriate length of the critical structure that one should
contour. This may result in suboptimal plan. Applies to
both target and critical structures.
5.4. Miscommunication; Dosimetrist exported one of the trial plans rather than the
inattention, final plan. This also may be difficult to detect as the
1.1. lack of procedure Very wrong dose; Very dosimetrist may be the preson importing the plan into
1. Plan OK to go to 1.2 Inadequateprocedure wrong dose distribution R&V system and the QA plan may also be generated for
135 9 - Plan Approval 2. Wrong plan 4.44 8.00 7.33 257.6 20
treatment 1.3 Procedure not followed Very wrong volume an incorrect plan.
2. Enter prescription 2. Incorrect dose Explanation in the above box (#17) applies but in this
8 - Treatment
95 + planning prescription and dose B. 8. Human error by the planner Very wrong dose 5.67 7.78 5.22 245.9 21 case instead of the physician making the error, the
Planning
constraints limit constraints planner makes the error.
1. Omission in entry Historical information about patients treated in the dept. is
maintained in a database. The archive is incomplete and
Entry of patient data
1- Patient 2. Incorrect or 8. (Human transcription error), 1.2, there are no other records (or no effort is made to get the
in electronic
3 Database incomplete previous. 1.3, 1.4 Very wrong dose 4.13 8.88 6.88 245.8 22 other records such as paper chart). The patient & family
database or written
Information treatment history don’t remember treatment (or details) and no-one notices
chart
2. Incomplete patient history physical changes from the prior treatment (tattoos). Part
5.3 (Source of data incomplete) of previously treated area is re-treated.
Specify inappropriate Omit 4D
protocol 6.1, 1.4 (Ignorance of available
Specify inappropriate methods, protocols, protocol
6 - Initial Treatment Specify image tolerances for requirements) Wrong location
43 Planning Directive registration goals – registration 5,3 (Miscommunication) Wrong volume 5.71 7.00 6.00 245.3 23
(from MD) 4D Specify wrong 1.1/1.2 (Lack of eplicit protocol)
reference image 8. (User error)
dataset (primary)
2. Wrong treatment 5.2 Poor communication With IMRT treatments, this failure is probably less likely
11 - Day 1 Set treatment accessories Human error Very wrong dose Very unless using a compensator-based approach.
189 5.56 8.00 5.33 240.0 24
Treatment parameters (Missing/incorrect Incorrect documentation wrong volume
bolus, blocks)
2. Wrong imaging study 2.5 User error
(correct patient) 1.1-1.6 Standards, procedures,
Wrong dose distribution Choose inhale rather than exhale CT study, or MR T2
Viz.; wrong phase of 4D protocols
Import images into Wrong volume rather than MR T1-gadolinium scans for anatomy and
52 7 - RTP Anatomy CT selected for 5.2-5.4: Communication (poor) 5.38 7.25 6.13 239.6 25
RTP data base target volume. Leads to wrong anatomical model (leading
planning; wrong MR for 6.1 Inadequate training
to systematic geometric and dosimetric errors)
target volume
delineation
3.2, 1.2, (Lack of dept Plan design based on incorrect tolerance dose for critical
policies/documentation) OAR
Inappropriate or
4.6 (Lack of time)
incomplete target
6 - Initial Treatment Specify dose limits doses
6.1 (Inadequate training) Moderately suboptimal
47 Planning Directive goals, and and/or normal tissue 4.89 7.78 6.00 234.4 26
plan
(from MD) fractionation constraints specified or
5,1, 8.6 (Planner selects wrong
assumed.
protocol in absence of clear
physician directive)
Localization; (port
11 - Day 1 2. Images Human error;
187 films and/or other Wrong location 5.44 7.56 5.44 234.1 27
Treatment misinterpreted Inappropriate settings
localization devices)
2.2. Software error; All causes listed in the cause column may result in an
User selects wrong parameters for incorrect evaluation of DVH or IDLs etc.
DVH.
Wrong or inappropriate structure(s)
14. Evaluate plan
8 - Treatment Incorrect DVHs, IDLS, for DVH(s)
128 (DVH, isodose, dose Very wrong dose 5.00 8.11 5.44 230.7 28
Planning etc 3.2. Poor evaluation tools
tables, etc.)
2.5. Wrong normalization point
selected.
Inadequate commissioning
effectiveness
2.5-2.6 User error
3.2 Desgin
Boolean Very wrong dose Plan based on DVH for incorrectly combined structs,
1. Wrong structures 3.5 – 3.6 Assessment or
66 7 - RTP Anatomy combination of distribution 4.75 7.88 5.75 230.0 29 easily results in wrong plan optimization decisions, and
combined programming
delineated structures Very wrong volumes very wrong dose distribution and/or volumes.
5.2 Lack of communication
5.4 Misunderstanding
review own work
The cause may also be a “software limitation” – e.g., a
radiological path length correction may be correctly
implemented but may not be the best algorithm to use in a
2. or 3. Software or design error.
particular situation; it’s not a software error but rather a
3.2. Software limitation
8 - Treatment 6. Heterogeneity 1. Wrong or poor Wrong dose distribution; limitation. This situation probably occurs frequently – a
108 2.5. User choice of wrong correction 5.63 5.25 7.63 230.0 30
Planning correction algorithm Wrong dose heterogeneity correction algorithm that is not appropriate
model
to the situation is used for optimization and dose
calculation . Measurements in a situation duplicating the
treatment situation are difficult – most confirming
measurements are made in uniform phantom.
Inadequate characterization of Acquired data quality is not good. Input data is not
delivery system in the RTPS; measured accurately. This will result in poor beam
5. Calculate the
Absolute output modeling.
dose to the
Relative dose inside beam
8 - Treatment optimization points, Wrong dose; Wrong dose
107 2. Poor beam modeling Penumbra, leaf edge/end modeling 5.44 5.11 7.89 229.4 31
Planning and also calc the distribution
Outside beam
final dose
Buildup region
distribution
Transmission
Example: Causes are same as above except that MD

Changes in prescription
1.2. Inadequate department policy changes the dose per fraction.
dose (hence in MU)
12 - Day N Lack of attention/carelessness
207 Adapt to changes occurring after initial Wrong dose 5.11 7.11 6.11 228.6 32
Treatment 5.2. Poor communication
treatment not entered
into chart and/or R&V
Define structures as overlapping and non-overlapping
1. Incorrect according to institutional protocol following the rules of
classification of a treatment planning system. Deviation from such protocols
8 - Treatment 1. Specify ROI for A. 1.2. Ambiguous contouring
80 structure as Very wrong dose 5.11 8.11 5.44 228.3 33 or rules might lead to an incorrect classification of a target
Planning optimization process protocol
overlapping or non- or a structure as overlapping or non-overlapping resulting
overlapping in an overdose or underdose of the overlapped portion of
the target or the normal structure.
Lack or attention/carelessness Dose to patient is higher Example: MUs are recalculated and entered into R&V
Changes in prescription 1.2. Inadequate dept. policy (not or lower than MD and/or paper chart but the calculation is incorrect. There’s
12 - Day N dose incorrectly requiring second check of MU intended. The no policy of checking so the error is not caught.
208 Adapt to changes 5.00 7.13 6.25 227.9 34
Treatment entered into chart changes due to prescription consequences depend on
and/or R&V changes). how many treatments are
6.1. Poor training affected
Examples: Patients simulated with full bladder are not
instructed as to the importance of filling bladder before
each treatment so they are unaware that they need to do
Inattention on part of therapist this (or they “cheat” when they come to treatment). This is
Wrong dose Wrong
Special patient 1.2. Inadequate dept. policy because the instructions in chart are hard to find and a
12 - Day N Patient set up for dose distribution
199 preparation (e.g. full 1.1-1.4. Inadequate documentation 5.56 6.44 6.22 225.9 35 new therapist (unfamiliar with patient) is on the machine
Treatment treatment Wrong location
bladder) not done in chart so the therapist fails to remind the patient to do the
special prep.
Effects: Target and critical organs (bladder, bowel) are in
different positions than at simulation – therefore, get
wrong doses at treatment.
5.4. Miscommunication; Dosimetrist exports a wrong plan to R&V system and
inattention, based on the wrong plan enters an incorrect prescription
1.1. lack of procedure Very wrong dose; Very for MD approval.
2. Completion of
2. Wrong total dose, 1.2 Inadequateprocedure wrong dose distribution
139 9 - Plan Approval formal prescription 4.00 8.56 6.22 225.4 36
fractionation 1.3 Procedure not followed Very wrong volume
after planning
Inattentiveness Severity passed on unobserved movement on one

11 - Day 1 Treat patient- 1. Failure to notice Light level treatment.
190 Wrong location 6.00 4.78 7.89 224.4 37
Treatment Monitor treatment patient move 2.2 device failure (Poor monitor)
Specify inappropriate Target volume based on MR only when it should have

6.1, 1.4 (Ignorance of available
protocol encompassed visible and suspected disease on both MR
methods, protocols, protocol
Specify inappropriate and CT
6 - Initial Treatment Specify image requirements) Wrong location
tolerances for
42 Planning Directive registration goals – 5,3 (Miscommunication) Wrong volume 6.00 6.67 5.22 223.6 38
registration Specify
(from MD) MR/PET 1.1/1.2 (Lack of eplicit protocol)
wrong reference image
8. (User error)
dataset (primary)
Human error
Very wrong dose Very
2.2. Software error
wrong dose distribution
10 - Plan 11. Manual plan 1.2 Inadequate procedure
173 Incorrect modification Very wrong location 4.33 8.11 6.00 223.3 39
Preparation modification 1.3 Procedure not followed
Very wrong volume
Examples: Field sizes or gantry angles or indexed couch

positions inadvertently changed because user overrides
3.2. Poorly designed or poorly
R&V settings acquired on Day 1. Patient is subsequently
implemented R&V system security
treated with these because
2.5. Careless use by untrained
a. there is no confirming source of information (e.g. paper
person (e.g. incorrect couch
chart) or
coordinates captured on Day N after
b. therapist doesn’t look at the paper chart and/or
correct ones were captured on Day Wrong dose Wrong dose
c. No one does a visual check of the situation before
Information in R&V 1) distribution
12 - Day N Patient set up for beaming on so an odd LINAC configuration isn’t noticed
202 system improperly Careless editing of information in Wrong location 4.67 7.22 6.44 223.3 40
Treatment treatment (everything is done from outside the room)
changed. R&V Wrong volume
Effects: Depending on how long this situation persists,
1.2. Inadequate department policy
patient can get seriously wrong dose distribution
1.1-1.2. No second source of
compromising tumor control or causing normal tissue
treatment
complications which may be severe.
information against which to check
Malice (sabotage)
Note: I’ve never seen “malice” as a cause but it is
certainly possible!
Different scaling factors used for RO defined contours and

Incompatible DICOM formats,
CT anatomy when transferred to TPS. Patient treated
limitations of treatment planning
systems or scanners
Incorrect handling of
DICOM RT objects Inadequate commissioning and Very wrong dose
5 - Transfer images Incorrect transfer of
(other than images) acceptance testing distribution
39 and other DICOM interest points or 4.78 7.89 5.56 222.4 41
between the scanner Standards/procedures/protocols (in Very wrong volume
Data contours
and treatment this case commissioning/acceptance
planning system testing) 1.1 thru 1.6
2.5 Materials used incorrectly
3. Design (3.2, 3.6)
Dose to patient is higher or lower than MD intended. The

consequences depend on how many treatments are
affected (+/- 1 treatment at conventional fractionation has
Changes in number of only minor effect, +/-5 is probably serious). Example: a.
fractions occurring after MD changes # of fractions but fails to make the change
1.2. Inadequate department policy
initial treatment clear in paper chart and/or does not tell the appropriate
12 - Day N Lack of attention/carelessness
206 Adapt to changes (increase or decrease) Wrong dose 5.00 7.13 6.25 222.1 42 person (physicist, dosimetrist, therapist) to make the
Treatment 5.2. Poor communication
incorrectly scheduled / change in the electronic (R&V) and paper charts. ..OR….
not applied to patient’s b. The person who is supposed to update the chart(s)
treatment forgets and doesn’t do it.
Effects: Patient stops tx early or is continued on tx for
more days than MD intends.
2. Failure to notice Example: Failure of MLC to move.

11 - Day 1 Treat patient- Wrong dose
191 inappropriate machine Inattentiveness 3.33 8.22 8.22 221.7 43
Treatment Monitor treatment Wrong volume
operation.
Contours on ROI are not extrapolated correctly; viz., for
external contour the sup and inf most contours are
8 - Treatment 1. Specify ROI for 2. Incorrect ROI A. 2.2. Inadequate contour capping
83 Wrong dose 4.67 6.78 6.89 221.1 44 extrapolated infinitely (i.e. add 10 cm length). The same is
Planning optimization process volumes algorithm
true for internal contours also. This can result in
suboptimal plan.
Planner is not knowledgeable on how the optimization
1. Incomplete or engine works. S/he sets up non-optimized constraints and
2. Enter prescription E. 6.1. Lack of understanding of the
8 - Treatment incorrect set of parameters. This may result in a plan that is suboptimal
93 + planning optimization engine by the Planner, Suboptimal plan 5.89 6.11 5.67 219.9 45
Planning objectives and and yet acceptable by the physician. Better training of the
constraints poor training
constraints planner could have resulted in a better plan.
3. Resulting structures effectiveness
ambiguously or 2.5-2.6 User error
incorrectly named 3.2 Desgin
Boolean Very wrong dose Plan based on DVH for incorrectly combined structs,
resulting in incorrect 3.5 – 3.6 Assessment or
68 7 - RTP Anatomy combination of distribution 4.25 7.88 5.88 218.9 46 easily results in wrong plan optimization decisions, and
correspondence of programming
delineated structures Very wrong volumes very wrong dose distribution and/or volumes.
treatment 5.2 Lack of communication
goals/constraints and 5.4 Misunderstanding
structures 6.1 Inadequate training
review own work
2. Enter prescription 2. Incorrect dose
8 - Treatment
96 + planning prescription and dose C. Other failure Very wrong dose 5.40 7.00 5.20 216.0 47
Planning
constraints limit constraints
2. Use margin width or
protocols for PTV 1 (all) Procedure failure
construction that are 5.2-5.4 Communication failure Did not define PTV correctly, resulting in not enough
Wrong dose distribution
64 7 - RTP Anatomy PTV construction inconsistent with dept 6.1Inadequate training 6.25 5.63 6.25 215.8 48 margin for target, leading to potential target miss or
Wrong volumes
procedures Inattention, lack of time, failure to underdose.
review own work
Pacemaker, prior treatment, etc.. Very wrong dose Very Pacemaker avoided in the treatment plan but forgets to
1. Entry of 3. Critical patient 1.2 Inadequate procedure wrong dose distribution make note to restrict size of port film or MV cone beam;
10 - Plan
147 demographic information not 1.3 Procedure not followed Very wrong volume 3.89 8.56 6.56 213.4 49 therefore, device receives dose that makes it malfunction
Preparation
information recorded 6.1 Inadequate training/orientation Non-radiation dose injury
Wrong user input. User error results in setup DRRs at wrong angles. Patient
4. Prepare DRRs, Incorrect images 1.2 Inadequate procedure is shifted unnecessarily
10 - Plan
159 other localization (wrong angle, wrong 1.3 Procedure not followed Very wrong volume 4.78 8.33 5.11 212.8 50
Preparation
imaging data divergence, etc) 6.1 Inadequate training/orientation
Beside dose constraints there are other parameters that

7. Setup
need to be selected to get the optimum results. These
optimization
parameters are Beamlet size, step size, algorithm,
parameters and
Stopping criteria, Max. # of segments, # iterations,
perform 1. Wrong parameters Human failure
smoothness of fluence, fixed jaw setting etc. These can
8 - Treatment optimization. selected. 2. 2.2. Software error
110 Wrong dose distribution 5.44 5.56 6.67 212.4 51 be chosen incorrectly by the planner.
Planning Beamlet size, step Bad parameters 1.3. Wrong departmental policy
If these are not chosen correctly then the MUs can be
size, algorithm, selected
higher and also one cannot possibly achieve the desired
Stopping criteria,
optimization.
Max. # of segments,
Software cannot handle certain selected parameters
# iterations
causing the optimization to fail.
Superficial parts of target have modest underdosed. TCP
compromised.
(For electrons, underlying critical structures are
overdosed – but this really isn’t an issue for current IMRT
1.1-1.3. Poor documentation in
which is photons only)
electronic and/or written chart
Examples: Prescribed bolus is omitted for one or more
Bolus not applied as 1.1-1.4. Position of bolus
treatments because a new therapist doesn’t notice
12 - Day N Patient set up for prescribed (omitted, inadequately described Wrong dose Wrong dose
197 5.67 6.44 5.67 212.1 52 instructions for bolus.
Treatment treatment wrongly positioned or Inattention of therapist distribution
Wrong thickness (e.g. 1 cm instead of 0.5 cm) is used.
wrong thickness) Custom bolus not labeled with
Effects are probably of minimal importance for photons
patient’s name.
but can be disastrous for electrons in settings where the
bolus is used to protect underlying normal tissue.
Note: R&V doesn’t note absence of bolus.
1 Procedure failures Suboptimal plan

2.1 – 2.3 Equipment availabilit or (worst case wrong dose
Drawings generally correct but have inappropriate spikes,
effectiveness distribution)
Delineate GTV/CTV sharp corners, etc. Could be detected with review, but is
3. Poorly drawn 2.5-2.6 User error
(MD) and other probably not corrected very often. Systematic “local”
contours (spikes, 3.2 Desgin
60 7 - RTP Anatomy structures for 6.50 4.88 6.13 211.6 53 geometric flaws in target design, leading to misses or
sloppy, etc) 3.5 – 3.6 Assessment or
planning and extra plan complexity. Errors in External surface and
programming
optimization density-related structures also can lead to significant
dosimetric errors. Wrong dose distribution in worst case
review own work
Input parameters required by the sequencer and the
planning system need to be compatible with each other.
But somehow the planner inputs a set of parameters that
is not compatible between the sequencer and the
3.2. Poorly designed interface. planning system requirements. This is caused because of
10. Run leaf
8 - Treatment 4. Wrong user 6.1. Bad training. the reasons stated in the cause column and results in the
120 sequencing to create Wrong dose distribution 4.44 7.44 6.22 210.9 54
Planning parameter selection 6.1. Poor understanding of algorithm effects mentioned in the effect column. Example:
deliverable plan.
Collimator angle, FS, Segment angle, speed limit for MLC
(sequencer can create a higher limit for MLC but this may
not be usable for planning system etc (never used
separate sequencer. So, not sure what this really can be).
5. Misleading or
erroneous structure
names and/or other
effectiveness
Delineate GTV/CTV labels (e.g., color)
2.5-2.6 User error Very wrong dose
(MD) and other resulting in incorrect Wrong names or labels of structs can result in wrong use
3.2 Desgin distribution
62 7 - RTP Anatomy structures for correspondence of 5.00 7.00 5.86 210.0 55 of struct info, leading to overdose to normal tissue or
3.5 – 3.6 Assessment or Very wrong volumes
planning and treatment underdose/miss of target
programming
optimization goals/constraints and
structures
review own work
Examples: Therapists not required or not trained to check
SSDs that would indicate a change in patient shape (e.g.
AP SSD for patient set up by lasers on side tattoos).
Loose mask (which might indicate tumor shrinkage or wt
Changes in patient loss) ignored on H&N patient.
geometry (thickness Effects: If patient thickness has changed by several cm,
12 - Day N Patient set up for changes due to wt gain 1.2. Inadequate department policy Wrong dose Wrong the dose/dose distribution is incorrect. If the
198 5.89 5.44 6.56 209.9 56
Treatment treatment or loss, tumor growth or Inattention dose distribution immobilization has gotten loose, patient motion can result
shrinkage) ignored or leading to wrong dose distribution.
not recognized. Secondarily –if the MD is not informed about unusual
changes in thickness, tumor growth or radiation-
complication induced weight loss can be neglected for
several days, leading to medical problems.

2.1 Equipment availability
Editing masks, table, Forget to edit CT table or immobilization device out of
2.2 Equipment defective Very wrong dose
other non-patient anatomical representation, resulting in wrong density
73 7 - RTP Anatomy Incorrect editing 2.4. Commissioning distribution (near patient 5.13 5.50 7.38 206.4 57
data included in distribution or incorrect external contour definition. Could
6.1 Inadequate training skin surface)
scan info particularly affect surface dose
Inattention
Failure to review own work
Inadequately trained staff; Potential for very large isocenter positioning or volume
Isocenter and other Not recorded or 1.2 (inadequate procedures or forms errors.
special point incorrectly recorded for capturing attributes);
19 3 - CT/simulation coordinates (e.g. change in 8. (“human error” [inattention to Wrong location 4.67 7.89 5.11 205.8 58
recorded in software isocenter made but not detail];
and/or print documented) 4.1, 8.2 (Rushed process)

Boolean 5.2-5.4 Communication failure Very wrong dose Plan based on DVH for incorrectly combined structs,
2. Wrong Boolean
67 7 - RTP Anatomy combination of 6.1Inadequate training distribution 4.50 7.88 5.25 204.9 59 easily results in wrong plan optimization decisions, and
operation(s) used
delineated structures Inattention, lack of time, failure to Very wrong volumes very wrong dose distribution and/or volumes.
review own work
11 - Day 1 Position patient for 1. Incorrect treatment A..Human error Wrong shifts; Misinterpreted treatment plan
181 Very wrong location 5.00 8.56 4.67 203.4 60
Treatment treatment isocenter. Inattention to detail
11 - Day 1 Position patient for 2. Incorrect patient Wrong location; Wrong Wrong immobilization device or treatment aids
184 Human error 5.11 7.22 5.44 202.3 61
Treatment treatment position volume
Manual entry: Small error Wrong dose Wrong Some planning systems may not upload all treatment
1. Incorrect Tx info 2.
1.2 Inadequate procedure dose distribution parameters digitally to R&V. Error <10% is made in
10 - Plan Wrong Rx
169 9. Prepare e-chart 1.3 Procedure not followed Wrong location 5.78 5.56 6.00 200.4 62 manual entry of fractions or dose carried.
Preparation 3. Wrong patient/plan
6.1 Inadequate training/orientation Wrong volume
Example: The Brainlab Mini-MLC is a routine add-on to a
Varian LINAC. In the mode where Varis is working with
the Brainlab system, it fails to detect the condition of the
permanent (Varian) MLC. So the MLC leaves can block
part of the Brainlab field, even if the Brainlab leaves go to
Very wrong location Very the correct position. The patient gets the wrong dose for
R&V fails to detect 3.2. Software design flaws- software wrong dose the entire treatment. If there’s no physical observation of
12 - Day N incorrect treatment inadequate for special situations that Very wrong dose the light field, this goes undetected. If it’s an SRS
204 Load patient files 3.56 7.89 7.11 200.4 63
Treatment conditions in special are, however, allowed for treatment distribution treatment, that’s for the whole treatment. For a
situations on the machine Very wrong volume fractionated treatment, there is some chance that it will
only happen on one day (or that it will be caught at some
point during tx). Example: Most R&V’s don’t detect
presence/absence of blocks and I know Varis doesn’t
discriminate between upper and lower wedges (though
this is a minor effect compared to those mentioned
above).
1. Incomplete or A lot of time is spent trying to optimize a plan with the
2. Enter prescription
8 - Treatment incorrect set of D. Human error in entering cost wrong cost function parameters. This results in a
92 + planning Wrong dose 6.22 6.33 4.78 200.2 64
Planning objectives and function parameters suboptimal plan.
constraints
constraints
5.4. Miscommunication; Dosimetrists exports a wrong patient plan to R&V system
inattention, and based on the wrong plan enters an incorrect
1.1. lack of procedure Very wrong dose; Very prescription for MD approval.
2. Completion of
1.2 Inadequateprocedure wrong dose distribution
138 9 - Plan Approval formal prescription 1. Wrong patient 3.13 8.63 7.38 199.8 65
1.3 Procedure not followed Very wrong volume
after planning
2.5 User error

4. Incorrect 3D 1.1-1.3 Standards
transformation of image 2.2-2.3 Defective Materials Inconvenience (patient Images appear in wrong registration or scale or L/R or A/P
Import images into
54 7 - RTP Anatomy dataset to treatment (hardware or software) – also and staff) 3.75 8.13 6.50 195.8 66 or S/I reversal. Results in wrong target location,
RTP data base
coordinate system inadequate acceptance and/or inappropriate plan.
Wrong orientation/scale commissioning
6.1, 6.4 Inadequate training,
No departmental guidelines or templates exist on how to
1. Incomplete or
2. Enter prescription produce an optimal plan for a given disease site. In the
8 - Treatment incorrect set of B. 1.2. Incomplete plan optimization
90 + planning Suboptimal plan 5.56 5.44 5.56 195.3 67 absence of this information, a planner, experienced or
Planning objectives and protocol
constraints inexperienced, runs an incomplete plan optimization
constraints
protocol.
Assumes skin-mark based setup with weekly verification
2. Inadequate process
2.6, 3.6 (Procedure followed images Patient is marked correctly, but planning margin is
for marking/reproducing
correctly but based upon inadequate too small relative to random errors characteristic of
Physically marking isocenter relative to
assessment of preparation errors in procedure
isocenter setup point treatment planning
relation to PTV margin policies).
(e.g., tattoos) on policies and/or
21 3 - CT/simulation patient and/or verification process so Wrong location 5.50 6.88 5.13 194.4 68
6.5, 5.2 (Poor communication:
Immobilization that setup process
physician fails to specify proper
casts/masks/etc sigma >M/2.7 where M
setup fiducials or therapist
marked as needed. is PTV margin
erroneously selects setup)
assumed by planning
process
1. PTV not specified, or
5.2-5.4 Communication failure Wrong dose distribution Did not define PTV correctly, resulting in not enough
target coverage
63 7 - RTP Anatomy PTV construction 6.1Inadequate training Wrong volumes 5.14 5.71 6.43 192.6 69 margin for target, leading to potential target miss or
specified relative to
Inattention, lack of time, failure to underdose.
CTV
review own work
5.4. Miscommunication; Dosimetrist exports a wrong plan to R&V system and
inattention, based on the wrong plan enters an incorrect prescription
1.1. lack of procedure Very wrong dose; Very for MD approval.
2. Completion of
141 9 - Plan Approval formal prescription 4 wrong plan 4.14 8.14 5.71 192.4 70
after planning
1.2, 1.1(Lack of regular procedures) Potential for very large isocenter positioning or volume
6.1 (Inadequate staff training). errors.
Physically marking 1. Error in physically 8.1, 6.5 (Poor choice of setup points
isocenter setup point marking or (e.g. loose skin) or inadequate
(e.g., tattoos) on documenting isocenter number/location of setup marks)
20 3 - CT/simulation patient and/or setup point (e.g., 4.2, 4.6 (High frequency of large Wrong location 5.44 7.44 4.67 190.9 71
Immobilization tattoos) on patient shifts in simulation process due to
casts/masks/etc and/or immobilization lack of physician involvement)
marked as needed. casts/masks/etc.
8.2,4.1 (Rushed process)
There are situations where a branching structure

contoured on the CT sim is not recognized as a branched
structure by a planning system or the right and left
8 - Treatment 1. Specify ROI for 2. Incorrect ROI B. 2. Improper handling of branching
84 Wrong dose 4.89 6.89 5.56 190.9 72 branches are mixed. If one branch is more at risk than the
Planning optimization process volumes structures
other (because of the tumor location) it might be desirable
to evaluate them separately so it is important the planning
system allow this to be done.
Pre surgery MRI scan incorrectly selected for volume
Human error
definition and patient treated.
Poorly defined procedures
PET w/ vs w/o atten correction, various types of MR
Correct patient selected pulse sequences
1.2 (Inadequate standard/procedure)
5 - Transfer images Transfer secondary but incorrect study set Wrong dose distribution
and 1.3(Standard/procedure/practice
38 and other DICOM (MRI, PET) data selected (wrong site, Wrong volume 4.44 7.22 5.67 190.1 73
not followed)
Data sets wrong date, wrong
5.2 Lack of communications, 5.4
technique, etc.)
Misunderstood communication
Gather patient Data modified by a user or other user error

11 - Day 1 3. Incorrect treatment Very wrong dose Very
180 treatment C. Human error 3.78 8.56 5.56 188.8 74
Treatment data wrong volume
information
Human error Human error results in the wrong dose being entered in a
1.2 Inadequate procedure treatment plan.
10 - Plan 2. Specification of
150 2. Wrong prescription 1.3 Procedure not followed Wrong or very wrong dose 4.50 8.13 5.13 188.8 75
Preparation treatment course
1. Incorrect plan info User error causes incorrect transfer of sequencing data
10. Download into delivery system : 2. and/or treatment parameters from R&V to LINAC.
3.2. Poor interface leads to user wrong dose distribution
10 - Plan complete delivery Connect wrong
171 error Very wrong location 3.89 8.67 5.33 187.7 76
Preparation plan to delivery patient/plan in RTP with
3.6 Inadequate programming Very wrong volume
system wrong patient/plan in Tx
Delivery system
11 - Day 1 Position patient for 1. Incorrect treatment C. 2.2 Device failure
183 Wrong location 4.78 7.00 5.56 186.7 77 Lasers misaligned. Incorrect use of IGRT system
Treatment treatment isocenter. 6.1 poorly trained personnel
5.4. Miscommunication; There are two sets of fields (initial and boost). Therapists
inattention, treat both sets of fields due to their approval and
2. Completion of 1.2 Inadequateprocedure availability in R&V system
5. Premature
142 9 - Plan Approval formal prescription 1.3 Procedure not followed Wrong dose fractionation 4.33 8.22 4.78 185.4 78
signaturization
after planning 2.5 Used incorrectly
Lack of standardized procedures Marking on the immobilization device placed in incorrect

. position leading to incorrect isocenter location.
Personnel inadequately trained.
Faulty execution of Lack of double checking
immobilization
Patient
technique. Incorrect 1 Standards/procedures/practices
2- Immobilization positioning/immobiliz Wrong dose distribution,
7 position. Inadequate fit (all aspects listed 1.1-1.6) 5.11 5.78 5.78 185.0 79
and Positioning ation appropriate to wrong volume
Incorrect indexing. 2. Materials/Tools/Equipment (all
treatment
Erroneous aspects 2.1-2.6)
documentation. 3.2 Inadequate design specification,
3.3 Design process not followed
5: Communications (5.1-5.4)
6: Inadequate training/orientation
1.2-1.4 Inadequate procedures, Systematic dosimetric (or
communication geometric) error.
Import images into 5. Grey scale Wrong conversion table used, so densities are wrong.
55 7 - RTP Anatomy 2.3, and 2.5 User Error Suboptimal plan 4.88 4.75 8.00 183.0 80
RTP data base conversion Results in suboptimal or dosimetrically incorrect plan.
And inadequate CT/sim
commissioning
Examples: For these to happen on Day N, the R&V
system must be such as to NOT include shifts from Day 1
or the therapist has to override the R&V.
1. Shifts from initial simulation isocenter (points tattooed
at sim) documented illegibly or unclearly in the chart (e.g.
Therapist inattention
a 5 that looks like a 3) so therapist shifts by wrong
6.1. Poor training
Shifts of isocenter amount.
1.1-1.3. Poor documentation of shifts
established at Day 1 (or 2. Therapist ignores shifts documented in chart –
12 - Day N Patient set up for 1.2 - 1.3. Weak dept. policy (e.g.
196 at last correction time) Wrong location 4.56 7.22 5.33 181.8 81 isocenter can be off by >5 mm.
Treatment treatment therapists are allowed to freely
not applied or 3. Therapists shifts in wrong direction or by wrong amount
override the R&V values captured on
incorrectly applied through carelessness (e.g shifts left instead of right) or
Day 1 or input by planner).
misunderstanding of notation in chart
Effect: beams intersect with the wrong parts of anatomy –

miss intended targets, irradiate unintended normal tissue.
Pull up wrong patient’s record Patient treated on the basis of another patient’s volumes
{usually carelessness ! Not covered
in Canadian table} Very wrong dose
5 - Transfer images
Transfer primary Incorrect CT data set Closest categories are 2.5 distribution
32 and other DICOM 3.78 8.78 5.78 181.3 82
(CT) data set associated with patient (Materials/tools/equipment used Very wrong volume
Data
incorrectly), 6.1 Inadequate training
and 8.4 fatigue.
MD does not communicate to the planner the desired

1. Incomplete or objectives and constraints and possibly the beam
8 - Treatment incorrect set of A. 5.2. Lack of communication Wrong dose; Wrong arrangements. Without this information, a planner,
89 + planning 5.78 6.11 4.78 181.2 83
Planning objectives and between RO and the Planner dose distribution experienced or inexperienced, cannot produce an
constraints
constraints optimized plan. The consequence is wasted effort causing
in a treatment delay.
Specified Lack of dept policies/documentation Symmetric fields instead of non-divergent half blocked
inappropriately/incompl 8.2 (Lack of time) fields used for breast treatment.
Suggested initial
6 - Initial Treatment etely 8.XX (Lack of attention to detail.)
guidelines for beam Moderately suboptimal
45 Planning Directive 5.4 ,5.1 (Miscommunication) 5.75 5.38 5.25 180.9 84
angles, energies, plan
(from MD) Appropriate request is 6.1 (Inadequate training)
machine
not followed 2.6 (inadequate process for detecting
incomplete Rx’s)
MD draws target volume outside the skin contour by
mistake. Expansion of CTV to PTV or drawing of PRV
causes the target or critical structure to lie close to the
4. ROI expansion
8 - Treatment 1. Specify ROI for skin surface or extend outside of the patient contour. Dose
86 outside or close to the A. 2. Algorithm limitations Suboptimal plan 5.67 5.56 5.67 180.2 85
Planning optimization process calculations algorithms think the dose to the surface
outer skin contour
structure is low and increases the beam intensity resulting
in hot spots and inefficient delivery. This results in a
suboptimal plan.
Examples: Patient poorly positioned in alpha-cradle so he
slips inferior or rotates. Therapist doesn’t take pains to
line him up with lasers or with more sophisticated
methods.
Therapist inattention
Shoulder position in a H&N patient is variable because
6.1. Poor training of therapist
12 - Day N Patient set up for Immobilization aids Wrong location; Wrong shoulder pull strap not used or too loose and because
195 Poorly constructed /poorly designed 5.11 6.67 5.22 180.1 86
Treatment treatment incorrectly used volume patient has no permanent marks to indicate the proper
immobilization
shoulder position (e.g. tattoos to align with transverse
laser)
Effect: beams go through wrong parts of anatomy – miss
intended targets, irradiate unintended normal tissue.
8 - Treatment 6. Heterogeneity Wrong dose; Wrong dose Planner wanted to incorporate heterogeneity correction
109 2. Wrong on/off choice Human error 5.00 6.00 5.89 179.8 87
Planning correction distribution but by error did not turn the heterogeneity correction on.
Immobilization device excluded from dose calculation and
Properties of device not Inadequate commissioning: device
Radiological attenuation through the device was omitted from patient
consistent with properties not assessed
properties of dose distribution.
accurate dose delivery .
positioning aids are
2- Immobilization or artifact-free Communication failure so not Wrong absolute dose;
8 known to treatment 6.22 4.67 5.78 179.6 88
and Positioning verification imaging included in treatment plan wrong dose distribution
planners. (e.g.
attenuation, skin-
Inadequate procedures 2.6: Inadequate assessment of
sparing)
material/tools/equipment
3. Setup treatment 5.3. Ambiguous written directive and A beam energy is chosen that dos not return optimal dose
fields (machine, or communication. distribution.
8 - Treatment 4. Poor selection of
99 energy, MLC, beam Human error by the Planner Poorly optimized plan 5.63 4.88 6.13 179.4 89
Planning beam energy
angle, , beamlet 8. Poor choice of beam energy
size, etc.)
Overlap regions not handled correctly because of
software error.
1. Classification of overlap or non-overlap structure is not
1. Incorrect
handled correctly. For example, define a structure (instead
classification of a
8 - Treatment 1. Specify ROI for of PTV) with a certain name as overlapping structure but
81 structure as B. 2.2. Software error Very wrong dose 3.44 8.11 6.22 179.3 90
Planning optimization process because of software error it does not treat it as
overlapping or non-
overlapping structure.
overlapping
2. Part of the region of an overlapping structure overlaps
with other structures even though it is defined as non-
overlapping structures and vice-versa.
6.1. Poor training. Similar to the last one.
Inattention.
8 - Treatment 11. Evaluate leaf 2. Incorrect evaluation 3.2. Poorly designed evaluation
125 Very wrong dose 3.78 7.89 5.89 179.3 91
Planning sequences (ie, ok when not, etc) tools,
2.2. Software error.
Human error Inappropriate scripting or plan library is used to set up a

Inappropriate protocol Possible collision,
1.2 Inadequate procedure plan according to a protocol. The wrong field margins are
10 - Plan (viz., tolerance table, inappropriate tolerances
156 3. Delivery protocols 1.3 Procedure not followed 5.13 5.88 6.00 179.0 92 used.
Preparation wrong use of allowing wrong volume or
automation) dose
5. Calculate the Software cannot calculate dose correctly. This can be
dose to the checked by a good quality measurement.
8 - Treatment optimization points, 2.2. Software error
105 Error in dose calc Wrong dose distribution 3.50 7.25 7.25 177.3 93
Planning and also calc the Failure of commissioning
final dose
distribution
2. Incorrect/inadequate Larger than expected systematic preparation and inter-
immobilization; 6.1, (Inadequate training of fraction setup errors that are inconsistent PTV margin
Immobilized patient immobilization aids personnel.) policy compromising CTV coverage.
12 3 - CT/simulation set up on CT incorrectly applied 2.5 (Human error) Wrong location for dose 6.00 5.78 4.78 176.8 94 Assumes conventional weekly EPID imaging, with poor
simulator resulting in abnormally 2.2 (Device failure) soft-tissue contrast.
large random setup
error
Score based on patient not disclosing non-compliance or
4 - Other 2. Patient advised of 5.3 (Poor communication)
imaging proceeding in non-compliant condition.
pretreatment special requirements Special requirements 6.1, 6.3 (Poor training or coaching of
26 Wrong volume 6.22 5.11 5.11 176.7 95
imaging for CTV (e.g. fast before not respected patient)
localization FDG-PET)
CT images are flipped with treatment delivered to the
Data incompatibility, Incompatible DICOM formats,
wrong side of the body
e.g. Image mirroring limitations of treatment planning
(chilarity) or patient systems or scanners
5 - Transfer images orientation mismatch Very wrong dose
Transfer primary
34 and other DICOM Image interpretation Inadequate commissioning and distribution 4.33 8.78 4.67 175.7 96
(CT) data set
Data problems (pixel acceptance testing Very wrong volume
pitch/image size errors) Standards/procedures/protocols (in
See TG53 for other this case commissioning/acceptance
mechanisms testing) 1.1 thru 1.6
This is probable more at the commissioning level because
the physicist may configure the MLC incorrectly. For
example, the sequencer uses IEC convention and the
planning system uses Varian convention. This can give
rise to wrong sequence.
6.1. Bad training,
For example, for Varian MLC the moving direction is in the
10. Run leaf Inattention
8 - Treatment 5. Wrong machine x- direction with collimator at zero. But suppose the
121 sequencing to create Confusion Wrong dose distribution 3.89 7.67 6.00 175.4 97
Planning configuration planning system set the collimator at 90 degree and
deliverable plan. 2.2. Software error
solves for the motion of the leaves along x-direction. But
the sequencer my interpret this incorrectly and assume
the motion to be along the y-jaw.
Chances are really very slim.

inattention to detail
Gather patient
11 - Day 1 2. Incorrect treatment 2.2 Hardware failure Very wrong dose Very
177 treatment 3.38 8.38 6.00 174.3 98
Treatment plan for patient. 5.2 Poor communication wrong volume
information
1.3, 5.3 (Lack of communication Study less useful than hoped. Possibility of moderate
between auxiliary dept. and Rad preparation error in localizing CTV relative to isocenter.
4 - Other Poor positioning
Onc) Compromised TCP. High D because radiology tech is
pretreatment 3. Patient set up for RT immobilization not
27 Wrong location 6.00 5.33 5.33 171.7 99 unlikely to reschedule procedure.
imaging for CTV imaging used
1.2 (Lack of formal procedures.)
localization
4.1, 4.6 (RO staff not available)
Inadequate commissioning Everything stated in the cause column can cause error in
12. Transfer
2.2. Incomplete or failed transfer. the final dose calculation.
sequencer results to RTP (Dose calculation
8 - Treatment 2.2. Software error
126 RTP ( should it not algorithm) gets wrong Very wrong dose 4.00 7.67 5.22 170.8 100
Planning Bad data
be TPS?) for final intensities.
Data handling error
dose calc (if needed)
Bad interface definition
2.5 Human error
6.1 Inadequate training and 8.4
fatigue.
But could also be.. Very wrong dose
1. Wrong patient’s 1.1-1.6 distribution Select images from wrong patient (name collision, human
Import images into
51 7 - RTP Anatomy images selected or Standards/procedures/protocols Very wrong volume 4.38 7.88 4.63 170.5 101 error). Causes incorrect patient anatomical info or mixes
RTP data base
imported (commissioning/acceptance testing) data from two patients.
2.2 Defective materials (software or
hardware)
3.2 Inadequate design specifications
3.6: Inadequate programming
3. Setup treatment Human error by the Planner. Very wrong dose Planned isocenter is different from marked isocenter for
fields (machine, 2.2. Software error in information distribution. Very whatever reason i.e., instruction is not clear,
8 - Treatment 6. Incorrect selection of
101 energy, MLC, beam transfer wrong location 4.22 7.78 4.78 169.3 102 communication is not established planner and therapists.
Planning isocenter
angle, , beamlet Wrong information input at sim Wrong dose
size, etc.)
Plan based on incorrect geometry – wrong treatment data
Documentation of
sent to machine (potential for left-right reversals). Patient
unusual simulation
treated incorrectly because simulation conditions are not
attributes (in print or
duplicated. Plan based on incorrect geometry – wrong
software), e.g., 1.2 (inadequate procedures or forms
treatment data sent to machine (potential for left-right
Unusual patient for capturing attributes)
Simulation attributes Very wrong location reversals).
positioning (prone or
17 3 - CT/simulation not correctly Wrong dose 4.22 8.33 4.89 168.8 103
feet-first) or patient 8. (Inattention to detail.)
documented.
preparation needs 6.1 (Poorly trained personnel.)
(e.g. simulated with
full bladder so need
to treat with full
bladder”)
Boolean combination 1. (all) Unknown software

structure representation limitation/error due to Inadequate
Boolean Systematic error leading Plan based on DVH for incorrectly combined structs,
incorrect due to acceptance testing.
69 7 - RTP Anatomy combination of to wrong doses/dose 3.50 7.00 6.25 167.8 104 easily results in wrong plan optimization decisions, and
software error or failing 2.2 Software error
delineated structures distributions very wrong dose distribution and/or volumes.
to observe algorithm 2.5 Mis-use by user
limits 6.1 Inadequate training
MD draws target volume outside the skin contour by
mistake. The dosimetrist does not trim it within the skin
contour. Expansion by a dosimetrist of CTV to PTV or
4. ROI expansion drawing of PRV causes the target or critical structure to lie
8 - Treatment 1. Specify ROI for
88 outside or close to the C. Human error Suboptimal plan 5.50 5.38 5.50 167.6 105 close to the skin surface or extend outside of the patient
Planning optimization process
outer skin contour contour. Dose calculations algorithms determine that the
dose to the surface structure is low and increases the
beam intensity resulting in hot spots and inefficient
delivery. This results in a suboptimal plan.
Personnel inadequately trained. Marking on the immobilization device placed in incorrect
Lack of double checking position leading to incorrect isocenter location.
Faulty execution of
1 Standards/procedures/practices
immobilization
Patient (all aspects listed 1.1-1.6)
technique. Incorrect
2- Immobilization positioning/immobiliz 2. Materials/Tools/Equipment (all Very wrong dose
6 position. Inadequate fit 4.67 7.44 4.78 167.0 106
and Positioning ation appropriate to aspects 2.1-2.6) distribution and/or volume
Incorrect indexing.
treatment 3.2 Inadequate design specification,
Erroneous
documentation.
1. Bad treatment The dose grid resolution may not be correct (viz. the
decisions due to bad dose policy may be to choose a dose grid of 2x2 mm but the
4. Setup dose
distribution. 2. Wasted planer chooses a grid of 5x5 mm. For small structure this
calculation
8 - Treatment 2. Poor parameters Human erro time and effort/ may lead to inaccurate dose calculation.)
104 parameters (eg 4.50 5.63 6.25 166.5 107
Planning selected 1.2. Wrong departmental policy 3. Patient treatment
calculation grid or
delayed
dose point density)
4. Undeliverable plan
All critical structures needed to generate an optimized

1. Incomplete or plan for a given disease site are not delineated.
8 - Treatment incorrect set of C. 1.3. All critical structures and/or Consequently, appropriate constraints for these critical
91 + planning Suboptimal plan 6.22 6.00 4.22 164.9 108
Planning objectives and target volumes not delineated structures will be missing in the generation of an
constraints
constraints optimized treatment plan. This may result in delivering an
unacceptable dose to the critical structures.
Very wrong dose; Very Software exported wrong or incomplete set of files to R&V
1. Plan OK to go to 2.2. Software or database errors; wrong dose distribution system. This is could be detected during the QA.
136 9 - Plan Approval 2. Wrong plan 2.67 8.22 7.33 164.2 109
treatment 3.6 Inadequate programming Very wrong volume
5.4. Miscommunication Exported a treatment plan for wrong Mr. Jones to record
inattention and verify system. The error could be discovered during
1.1. Lack of procedure; Very wrong dose; Very the import into record and verify system or during plan
1. Plan OK to go to 1.2 Inadequate procedure wrong dose distribution QA.
133 9 - Plan Approval 1. Wrong patient 3.78 8.78 5.33 163.9 110
treatment 1.3 Procedure not followed Very wrong volume
2.5 Equipment used incorrectly
2.5. Manual entry error Wrong ID is entered for a patient with the same name.
Mistaken info Plan is eventually exported to wrong patient and treated.
1. Entry of wrong dose distribution
10 - Plan 1.1, 1.3. Wrong identification
144 demographic 1. Bad info entered Very wrong volume 3.67 8.56 5.22 163.4 111
Preparation 1.2 Inadequate procedure
information Very wrong location
1. Incorrect patient Incorrect data base. Incorrect transfer from database to

records used (Wrong machine.
Gather patient
11 - Day 1 chart selected Very wrong location Very
176 treatment inattention to detail 3.33 8.56 5.89 163.2 112
Treatment Wrong database file wrong dose
information
selected)
Gantry rotation is performed automatically (e.g. acquiring

a cone-beam scan) or from outside the room) without an
in-room check that the motion can be performed without
collision. The check is not made either because there is
Gantry or other LINAC no dept. policy requiring such or because the therapist is
12 - Day N Carelessness Non-radiation-related
210 Treatment delivered hardware (e.g. OBI) 3.33 9.11 5.44 162.8 113 rushed or careless. Another scenario is one where the
Treatment 1.2. Poor departmental policy physical injury
collides with patient patient moves during treatment (e.g. arm dangles off
couch) so that even if initially the gantry cleared, it does
not now. Due to inattention, no one notices that the patient
has changed position and continues to rotate the gantry
from outside the room.
1. Incorrect plan info Software error causes incorrect transfer of sequencing
10. Download into delivery system : 2. data and/or treatment parameters from R&V to LINAC.
10 - Plan complete delivery Connect wrong 2.2. software error
170 Very wrong location 3.50 8.75 5.13 161.3 114
Preparation plan to delivery patient/plan in RTP with 3.6 Inadequate programming
Very wrong volume
system wrong patient/plan in Tx
Delivery system
Deliverable plan may not be created because of error in
sequencer because of software error such as incorrect
interpolation of parameters; or algorithm limitations, for
example planning system requires a field size of 10x10
and the leaf sequencer generates a leaf distribution that
10. Run leaf
8 - Treatment 2.2. Software error. Wrong dose distribution. requires a 14x14 field size; or planning system can handle
117 sequencing to create 1. Error in sequencer 3.78 7.89 4.89 160.7 115
Planning 3.2. Algorithm limitation. Wrong dose only 100 segments but the leaf sequencer generates 120
deliverable plan.
segments. Or planning system requires a split field but the
leaf sequencer cannot generate a split field.
Software error: Example: You enter 10 cm x10cm FS but
the software error can give you a different FS
1. Incorrect/inadequate Significant isocenter positioning/treatment volume error.

6.1, (Inadequate training of
immobilization; Likely noted on port images
Immobilized patient personnel.)
immobilization aids Very wrong location for
11 3 - CT/simulation set up on CT 2.5 (Human error) 4.75 7.50 4.38 160.3 116
incorrectly applied, dose
simulator 2.2 (Device failure)
resulting in large
>3sigma setup error
2.6 Inadequate assessment of MUs, sequencing or LINAC parameters do not transfer
1. Incorrect Tx info, 2. materials/tools/equipment for task correctly to R&V from planning.
10 - Plan Wrong Rx, 3.2. Bad interface
167 9. Prepare e-chart Very wrong location 3.88 8.63 4.75 158.3 117
Preparation 3. Wrong patient/plan 3.2 Inadequate design specifications
Very wrong volume
3.6 Inadequate programming
Pull up wrong patient’s record Patient treated on the basis of another patient’s volumes
defined on secondary data sets
{usually carelessness ! Not covered Very wrong dose
5 - Transfer images Transfer secondary
in Canadian table} distribution
35 and other DICOM (MRI, PET) data 1. Incorrect patient 4.22 8.00 4.89 157.9 118
Closest categories are 2.5 Very wrong volume
Data sets
(Materials/tools/equipment used
incorrectly”), 6.1 Inadequate training
and 8.4 fatigue.
2.5. Wrong patient chosen;
1. Entry of wrong dose distribution
10 - Plan 2. Failure to link to 1.2 Inadequate procedure
146 demographic Very wrong volume 3.89 8.67 4.88 157.9 119
Preparation external database 6.1 Inadequate training/orientation
information Very wrong location
In order to understand whether the leaf sequence is right

or wrong, one will have to generate i) the fluence profile
using the final leaf sequences generated by the
sequencer and compare it with the desired fluence profile;
1. Unintentional
8 - Treatment 11. Evaluate leaf 2.2. Software error, ii) one will have to generate the dose distribution and then
124 modification of Very wrong dose 3.44 7.89 5.78 157.2 120
Planning sequences User error determine whether the distribution is the desired one or
sequences
not. If it is not then it could be due to many reasons, one
of which is an incorrect leaf sequence. But the question is
how does one know whether the leaf sequence is correct
or not?
4. Setup dose Wrong region of interest is selected for calculation. For
calculation Wrong dose distribution example, a target or critical structure may be bound by a
8 - Treatment 1. Wrong parameters
103 parameters (eg Human failure, Software error leading to bad tx 4.50 5.88 5.88 157.1 121 rectangle of 20cm x30 cm dimension but the region of
Planning selected
calculation grid or decisions interest is chosen to be 10cm x10 cm
dose point density)
Deliverable plan may not be created because of error in
sequencer because of incompatible selection of
10. Run leaf Bad sequencer parameters chosen parameters. For example, to create a leaf sequence for a
8 - Treatment
116 sequencing to create 1. Error in sequencer or used., set by user or by Wrong dose distribution 4.22 7.00 4.67 157.0 122 given fluence distribution, the system may require 100
Planning
deliverable plan. configuration segments but the user may input 90 segments which will
be an error. This is dependent on the requirements of the
sequencer and may vary from sequencer to sequencer.
Converting CT 2.2 Equipment defective Try to remove contrast from CT by editing density info, but
(or maybe “suboptimal
71 7 - RTP Anatomy image intensity to Density map incorrect 5.2-5.4 Communication failure 4.38 4.25 8.25 155.6 123 do it incorrectly. Leads to wrong dose distribution (dose
plan” though that might be
density 6.1 Inadequate training typically <10% wrong).
too strong)
review own work
Lack of standardized procedures. Patient was immobilized with conventional 3D type
Personnel inadequately trained immobilization rather than more restrictive IMRT type
Poor communication as to goals of immobilization.
treatment
Inappropriate
Patient immobilization method.
1. Standards/procedures/practices Very Wrong dose
2- Immobilization positioning/immobiliz Incorrect position.
4 (all aspects listed 1.1-1.6) distribution 4.56 6.89 4.78 154.8 124
and Positioning ation appropriate to Wrong choice of
2. Materials/Tools/Equipment (all very wrong volume
treatment materials or
aspects 2.1-2.6)
accessories.
3.2 Inadequate design specification,
Examples: New therapist doesn’t realize that blocks are
Blocks used in addition
used in addition to DMLC and relies on an R&V system
to MLC are not placed.
(like Varis) that doesn’t prevent treatment if blocks are
(Many places may not
omitted. Therapist is careless and forgets to place blocks.
use blocks + IMRT, but
Effects: Usually this is a minor effect because, in IMRT,
we do, in some special
the blocks are used to reduce dose in already low
12 - Day N situations – e.g. 3-field 1.1-1.4. Poor documentation in chart
200 Place bolus Very wrong volume 4.44 5.89 5.44 153.9 125 intensity regions or to “smooth out” jagged leaf edges at a
Treatment breast with single isoctr Inattention on part of therapist.
junction (e.g. 3-field breast case). A collateral minor dose
to smooth out
increase over the whole field occurs because the MUs
matchline with
account for a tray factor and the tray isn’t there!
supraclav, some H&N
retreatments to provide
extra cord protection)
2.5 User error
1.2-1.4 Inadequate procedures or
Distortion corrections (for MR Distortion, for 4-D
communication
Import images into 6. Distortion correction Wrong dose distributions respiration changes) are applied incorrectly. Both
56 7 - RTP Anatomy 3.2 Design specification 3.50 5.50 8.00 153.9 126
RTP data base Wrong volumes geometry and dose can be affected – leading to over or
3.5 Assessment failure
underdose to target and/or critical normal tissues
6.1 Training failure
Also Inadequately tested software
Gather patient System change/system upgrade induced error
179 treatment B. 2.2. Software failure 2.89 8.78 6.00 153.0 127
information
1. Wrong parameters 2.2 Hardware or software failure by Human error (manually intervening in R&V followed by
11 - Day 1 Set treatment
188 uploaded to treatment machine or R&V Wrong dose 3.89 7.78 5.11 151.9 128 acquisition)
Treatment parameters
unit Human error
4. ROI expansion For the above situations the dose calculation algorithm
8 - Treatment 1. Specify ROI for
87 outside or close to the B. 2.2. Software error Suboptimal plan 4.89 5.78 5.56 151.7 129 may handle the situation correctly but an error of the
Planning optimization process
outer skin contour software causes an unpredictable error
Very wrong dose For planning systems which use separate software or
9. Transfer distribution. system to convert fluence to leaf sequence, export of
Wrong patient or plan selected for
8 - Treatment optimized fluence to 1. Wrong patient or Wrong dose wrong fluence to the leaf sequencer or input of leaf
113 transfer. 3.33 7.11 5.00 151.6 130
Planning leaf sequencer – if plan Wrong location sequence into the TPS for the wrong patient can lead to
Confusion in patient/plan ID info
separate system Wrong volume incorrect radiation treatment.

Editing density map Wrong dose distribution Try to remove contrast from CT by editing density info, but
2.2 Equipment defective
for imaging (or maybe “suboptimal do it incorrectly. Leads to wrong dose distribution, though
70 7 - RTP Anatomy Incorrect editing 5.2-5.4 Communication failure 4.75 4.50 7.13 151.0 131
artifacts,e.g., plan” though that might be error is localized, most likely (dose typically <10% wrong).
contrast and bolus too strong) .
review own work
Very wrong dose; Software exported a wrong or incomplete set of data files.
Very wrong dose This is more difficult to detect and may be detectable only
1. Plan OK to go to Software or database errors;
134 9 - Plan Approval 1. Wrong patient distribution 2.89 8.78 6.22 150.6 132 through QA.
treatment 3.6 Inadequate programming
Very wrong volume
Two courses:
1. The fluence file is incomplete (not corrupt as in item
49). This is then input into the sequencer. An incomplete
10. Run leaf 3. Sequence file or fluence file input into sequencer will result into an
8 - Treatment
119 sequencing to create output incomplete or 2.2. Sequencer software error. Wrong dose distribution 3.67 6.67 5.78 148.7 133 incomplete output of the sequencer.
Planning
deliverable plan. incorrect
2. Fluence is correct but the software error may cause
wrong leaf sequence output.
5.2 Poor communication
Misinterpreted treatment plan
11 - Day 1 Position patient for 3. Incorrect patient Wrong location; Wrong
185 2.2 Incompatibility between 4.00 7.78 4.33 148.3 134
Treatment treatment orientation volume
treatment machine and R&V system
2, Patient medical Inappropriate dose for new condition. There may be some
condition changes events (e.g. drug interactions ) that would have more
11 - Day 1 Take patient into the between prescription serious consequences
175 5.2 Poor communication Wrong dose 4.33 6.44 5.56 147.3 135
Treatment treatment room and treatment (dental
situation, wt
changes)Com
Min: Confusion and
2.5 Human error inconvenience
Create case (define 1. Misidentification 6.1 Inadequate training Max: Very wrong dose Mistype patient name or ID. Causes wrong anatomical
49 7 - RTP Anatomy 4.75 7.63 4.25 147.0 136
patient in RTP db) (Wrong name) 8.4 fatigue. (distribution, absolute and model to be used for planning.
volume)
1.Incorrect More structures contoured than the software allows with

C. 2.5 Software limitations.
classification of a unpredictable effect on optimization
8 - Treatment 1. Specify ROI for Viz., Overrunning the number of Poorly optimized
82 structure as 4.89 7.44 4.11 145.7 137
Planning optimization process overlapping structures which are treatment plan
overlapping or non-
allowed
overlapping
MRI images are flipped with treatment delivered to the
Incompatible DICOM formats,
Data incompatibility, wrong side of the body
limitations of treatment planning
e.g. Image mirroring
systems or scanners
(chilarity) or patient
orientation mismatch Very wrong dose
5 - Transfer images Transfer secondary Inadequate commissioning and
Image interpretation distribution
37 and other DICOM (MRI, PET) data acceptance testing 4.00 8.33 4.22 145.6 138
problems (pixel Very wrong volume
Data sets
pitch/image size errors)
Standards/procedures/protocols (in
See TG53 for other
this case commissioning/acceptance
mechanisms
testing) 1.1 thru 1.6
Lack of standardized procedures. Patient immobilized with dentures in and treated with
QA checks dentures removed.
Personnel inadequately trained
Suboptimal Poor communication as to goals of
immobilization method. treatment
Incorrect position.
Patient Suboptimal treatment
Wrong choice of 1 Standards/procedures/practices
2- Immobilization positioning/immobiliz Inconvenience (patient
5 materials or (all aspects listed 1.1-1.6) 5.22 4.78 5.00 140.4 139
and Positioning ation appropriate to and staff)
accessories. Poorly 2. Materials/Tools/Equipment (all
treatment
fitting mask, aspects 2.1-2.6)
Best/Typical Case 3.2 Inadequate design specification,
1. Measurements not
made
2. Measurements are
Other setup data incorrect.
1.1, 1.2, 1.4 (Lack of regular
acquired and 3. Measurements are
procedures)
documented in chart not clearly Wrong location
6.1 (Inadequate staff training.)
22 3 - CT/simulation (e.g. caliper or ruler documented., e.g., Wrong dose 5.00 6.11 4.44 140.4 140
8. (Inattention to detail.)
measurements of (photos unclear or don’t
4.6, 4.1 (Rushed process)
“AP setup depth”, show key features of
setup photos) setup such as arm
position or setup mark
locations)
Wrong user input. Normal tissue is mistaken for a tumor resulting in

6. Define, annotate Wrong volume (Set
Incorrect anatomy 1.2 Inadequate procedure geometrical miss.
10 - Plan anatomical info to be patient at incorrect
163 visualization or 1.3 Procedure not followed 4.43 6.86 4.00 140.0 141
Preparation used in localization position. Geometrical
identification. 6.1 Inadequate training/orientation
process miss. Failure.)
11 - Day 1 Position patient for 1. Incorrect treatment Incompatibility between treatment machine and R&V
182 B. 2.2 Device failure Wrong location 3.67 8.33 4.56 139.7 142
Treatment treatment isocenter. system. Should be found during acceptance testing.
likely to mix up 2 patients treated similarly –prostate and
breasts with same laterality come to mind. It is even more
likely if pts have same last name- even more likely if they
Very wrong location Very
Wrong patient (records Inattention on part of therapist look alike so facial photo is unclear identifier. It is more
wrong dose
upon which treatment 1.2. Inadequate department protocol likely if there are frequent changes of therapists, so
12 - Day N Very wrong dose
194 Patient enters room will be based for patient identification 3.67 6.56 5.22 138.6 143 therapists are unfamiliar with patient. More likely if
Treatment distribution
correspond to a 1.3. Failure to follow dept protocol therapists don’t note OTHER aspects of patient after
Very wrong volume
different patient) setup (e.g. AP and lateral SSDs) which might be different
s=4~9
between two Jim Joneses.
Effects: patient gets fields and doses intended and
customized for another
2.5 Human error
8.4 fatigue.
But could also be: Min: Confusion and
1.1-1.6 inconvenience Mistype ID.
Create case (define 2. Wrong or non-unique
50 7 - RTP Anatomy Standards/procedures/protocols Max: Very wrong dose 4.25 7.63 4.13 137.5 144 Causes some incorrect patient anatomical info or imaging
patient in RTP db) ID
(commissioning/acceptance testing) (distribution, absolute and info – potentially mixing data from two patients
2.2 Defective materials (software or volume)
hardware)
3.2 Inadequate design specifications
Very wrong dose
distribution
4. Topologically 2.1 – 2.3 Equipment availabilit or
Very wrong volumes
inconsistent contours effectiveness
Delineate GTV/CTV
2.5-2.6 User error Loops or overlaps can cause clearly wrong anatomical
(MD) and other
Overlaps, loops, other 3.2 Desgin model, leading to very wrong anatomy and/or dose
61 7 - RTP Anatomy structures for 5.00 6.63 4.00 137.4 145
potential algorithm 3.5 – 3.6 Assessment or distribution. Highly RTP system dependent as to whether
planning and
problems programming wrong result or crash/error is the most common outcome.
optimization
review own work
1 (all) inadequate procedures Mislabeling or use of CT Scans, or combination of multiple
2.1 Equipment availability image sets with same name and different field of view or
Creation of 3-D 3-D Voxel
2.2 Equipment defective location coordinates can lead to wrong external volume
anatomical representation Wrong dose distribution
75 7 - RTP Anatomy 2.4 inadequate commissioning 3.57 6.00 6.57 136.1 146 description. Wrong external contour can result in wrong
representations from problems Wrong volumes
2.5 User error voxel representation in every planning system. Use of
contours
2.6 (Inadequate commissioning) unevenly spaced CTs can cause problems in some
6.1 Inadequate training systems.
Software input error: 8. (Inattention Potential for very large isocenter positioning or volume
to detail) , 6.1 (poorly trained errors.
personnel)., or 1.2 (inadequate
Unusual patient
Patient position procedures)
position not handled by Very wrong location
properly represented
18 3 - CT/simulation image transfer Wrong dose 3.11 8.78 4.56 136.1 147
by image-transfer 2.2, 3.5, 2.6 (Software error with
software., e.g., L and R
software unusual positions not detected by
labels exchanged
Commissioning or error pathway not
compensated by simulation staff)
Very wrong location Inadequate checks

5.2 Poor communication Very wrong dose
11 - Day 1 Take patient into the 1. Incorrect patient in Inattention to detail. Very wrong dose
174 3.11 7.89 5.89 136.1 148
Treatment treatment room the room 6.1 Poorly trained personnel distribution
Very wrong volume
Human error MD prescribes BID but course is scheduled QD

1.2 Inadequate procedure
10 - Plan 2. Specification of 3. Wrong course
152 1.3 Procedure not followed Wrong dose fractionation 3.78 7.33 5.00 135.0 149
Preparation treatment course scheduling etc
Human error Human error leads to initial fields being treated the
1.2 Inadequate procedure number of fractions prescribed for the boost.
10 - Plan 2. Specification of 4. Fields not ordered
154 1.3 Procedure not followed Wrong dose fractionation 3.89 6.89 4.78 135.0 150
Preparation treatment course correctly (initial/boost)
Delivery recorded in Therapist is distracted – treats patient but doesn’t make

12 - Day N Treatment delivery is
214 paper chart (if Human error (inattention) Suboptimal plan 5.67 4.56 4.78 132.4 151 notation in chart.
Treatment not recorded in chart
applicable)
User error, transcription error. Very wrong dose Very The number of fractions is transcribed incorrectly.
1. Incorrect Tx info, 2.
1.2 Inadequate procedure wrong dose distribution Overdose or underdose possible.
10 - Plan 8. Prepare paper Wrong Rx,
166 1.3 Procedure not followed Very wrong location 4.89 7.89 3.56 130.8 152
Preparation chart 3. Wrong patient/plan
6.1 Inadequate training/orientation Very wrong volume
Not sure what “corrupted” means here but presumably a

software bug or electronic problem causes the file to be
12 - Day N MLC files (leaf motion) changed or, worse, disconnected from the treatment field
203 Load patient files 3.2. Software design flaws Very wrong dose 2.67 8.11 6.44 130.3 153
Treatment corrupted so either the wrong intensity pattern or an open field is
applied. Especially the wrong intensity pattern applied at
Day N would be almost impossible to catch.
For large fields the field may need to be split. This can
happen in two ways: 1) The sequencer splits the field, 2)
the sequencer asks the user to split the field. In Ist case
10. Run leaf the sequencer splits the field at the wrong place. In the
8 - Treatment 7. Error splitting large Split in wrong place,
123 sequencing to create Wrong dose 4.44 5.89 4.33 127.6 154 second place the user splits the field in the wrong place.
Planning fields for Varian MLC Used bad algorithm
deliverable plan. In either case, because of this error in splitting the field,
the sequencer generates a leaf sequence that is not
physically accessible by the MLCs. This will result in
effects described in comments
1.3, 5.3 (Lack of communication
between auxiliary dept. and Rad
4 - Other Onc) Inconvenience-patient
pretreatment b. Correct area imaged Inconvenience-staff
29 4. Scan performed 5.00 4.78 5.00 127.2 155
imaging for CTV with wrong protocol 1.2 (Lack of formal procedures.) Wrong volume
localization
6.1 (Inadequate staff training)
Drawing strangely-shaped contours, corners, loops, and

1 (all) inadequate procedures disconnected contours can cause surface creation
Creation of 3-D 2.1 Equipment availability algorithms to fail unexpectedly, and with strange
anatomical Flawed or erroneous 3- 2.2 Equipment defective Wrong dose distribution repercussions. A contour on one cut with a problem can
74 7 - RTP Anatomy 3.63 5.88 5.88 127.1 156
representations from D surface mesh 2.4 commissioning2.5 User error Wrong volumes lead to folded surfaces, surfaces with are compressed to
contours 2.6 (Inadequate commissioning) a point on that contour, etc. There is a reasonable
6.1 Inadequate training probability of not detecting this if the failure is localized
and no overall review of surfaces is performed.
Human error
1.2 Inadequate procedure
10 - Plan 2. Specification of 1. Wrong patient or Wrong or very wrong
148 1.3 Procedure not followed 2.86 6.86 4.71 126.9 157
Preparation treatment course plan dose and/or volume
11 - Day 1 1. Treatment not Likely to be noticed as discrepancy in record later – not

192 Record treatment Human error Wrong dose 4.67 5.67 4.22 126.0 158
Treatment recorded likely to affect multiple fractions.
5.4. Miscommunication;
inattention,
1.1. lack of procedure Very wrong dose; Very
2. Completion of
140 9 - Plan Approval formal prescription 3. Wrong site 3.25 8.50 4.50 125.0 159
after planning
11 - Day 1 Human failure Likely to be noticed.

193 Record treatment 2. Recorded incorrectly Wrong dose 4.88 5.00 5.00 123.8 160
Treatment 2.2. Software failure
Dose point definition
(for calculation of 2.5. User error Choose poor resolution or method for defining points. Or
dose on random 3-D points distribution 2.1-2.3 Software errors create composite points list from incorrect structures. Or
76 7 - RTP Anatomy mesh of points for errors 6.1. Inadequate training or 3.57 6.29 5.43 123.3 161 name points list incorrectly. Wrong choices lead to
Wrong volumes
DVH and understanding of algorithms situation that leads to software error. If points are very
optimization system incorrect, then dose or volumes can be very wrong.
use)
2.2 Equipment defective
Editing anatomical 1. Incorrectly reaching
2.3 Inadequate maintenance Very wrong dose Adding too many structs or contours may overwrite other
model to conform to system limits for
72 7 - RTP Anatomy 2.5 Equipment used incorrectly distribution 3.63 6.63 4.38 119.1 162 objects, with very unpredictable results. Crashes may
limitations of the contours, structures,
5.2-5.4 Communication failure Very wrong volumes occur, or potential for wrong dose or volume.
TPS etc
review own work
1.2 or 3.2 (Poor scheduling process: Study may be wasted or less valuable than intended.
4 - Other Study scheduled at bad scheduler not aware of clinical Study may need to be repeated.
1. Time of study is
pretreatment time relative to needs)) D is high because in many cases PET or functional MR
25 compatible with Wrong volume 5.33 4.44 4.44 117.7 163
imaging for CTV simulation or intended will not be repeated due to cost.
intended use
localization use. 5.3 (Poor communication).
Examples: In one version of Varian/Varis, not terribly long

ago, there was a sequence of actions under which the
state of the MLC at the end of patient J’s treatment
affected whether the DMLC would be present for patient
J+1’s first field. This could happen on any day of
treatment. The problem could be caught and quickly
ameliorated if someone observed that the MLC display on
File related to treatment the monitor was not changing and beamed off. Once the
12 - Day N 3.2. or software design flaws in linac Very wrong dose
201 Load patient files corrupted or incorrectly 2.89 7.22 5.22 117.2 164 cause was understood, it could be prevented by being
Treatment or R&V distribution
loaded careful to not go thru the causing sequence of operations.
I believe Varian has supplied a patch so this won’t happen
currently.
Effect: The effect, if not caught, was that a patient got
excess (could be factor of 2 to 3) dose with no modulation
for the first field. If this only happened once and treatment
was conventionally fractionated (and involved 4 -7 fields)
the effect was minor dosimetric error.
Contrast not used when
it is needed
(chronologically follows
5.2 (Inadequate communication from
Patient prepped for setup)
MD to sim staff).
imaging session Bladder or bowel prep
1.2 (General procedures (e.g. all
(contrast, not done
patients of a particular type have
13 3 - CT/simulation bladder/bowel, (chronologically done Wrong volume 5.11 6.00 3.56 112.0 165
contrast) not clearly documented
opaque markers on before pt comes in)
1.4 (procedure not communicated to
special points, Breathing control
new staff.)
breathing control) (gating or breath hold)
intended but not
available at simulation.
Inadequate
quality/Incomplete
Volume needed for Wrong volume
Images 1 1.4 (General procedures not
14 3 - CT/simulation treatment planning Wrong dose 5.00 5.56 3.89 109.8 166
1. Wrong scan protocol documented)
scanned
used (e.g. wrong slice
thickness/separation)
3.5. Failure to recognize the
1. Treatment volume
8 - Treatment 15. Evaluate delivery limitations of the delivery system, Suboptimal plan
130 inappropriate for the 3.71 5.14 4.71 108.4 167
Planning system limitations 6.1. Inadequate training Poor treatment used
delivery system
Support of multiple 2.5. User error Wrong dose distribution
Scans for different Original CT scan set could be mixed up or combined with
anatomical models 2.1-2.3 Software errors Wrong volumes
patient representations the scan set from a new anatomical site – or the two sets
77 7 - RTP Anatomy (ie, different body 6.1. Inadequate training or 3.67 5.50 5.00 108.0 168
combined or mixed up can be incorrectly registered with each other, leading to
parts) for same understanding of algorithms
wrong anatomical model (and thus dose).
patient
Patient name is typed into the database incorrectly
Errors in manual entry, most likely (misspelled; e.g. Yorke is spelled without the ’e’)
1- Patient causes: Information is requested from another department for
in electronic 1. Incorrect Patient ID
1 Database 8. (Human transcription error; Very wrong dose 3.78 7.89 3.89 106.8 169 Ellen York, a different person who actually exists.
database or written data
Information 5,3 (wrong data communicated to Information regarding Ellen York is sent back to the
chart
RO data entry) requesting dept..Incorrect staging/labs transcribed to pt
chart from outside. Suboptimal dose prescribed
Human error Bolus mislabeled or paired with wrong patient’s
immobilization devices and used on wrong patient
Patient-specific
2- Immobilization Hardware used on 1 Standards/procedures/practices Wrong dose
9 hardware labeling 3.78 6.89 3.89 106.6 170
and Positioning wrong patient (1.1, 1.2, 1.3, 1.4, 1.6) and 5.2 Lack distribution/wrong volume
(name)
of communications
The optimizer is not a good quality optimizer because the
Poor optimizer/optimization. optimization algorithm is inferior in quality.
1. Treatment plan has
Conflicting planning objectives and The optimizer could not return desired dose distribution
8 - Treatment significant failure
111 8. Run optimization dose constraints. Inconvenience (staff) 6.11 4.89 4.11 106.4 171 because of the conflicting choice of dose constraints and
Planning meeting planning goals
Inadequate evaluation. planning objectives. The objectives and constraints were
and objectives
not evaluated correctly when they were entered into the
optimizer.
Incorrect delivery system definition in Explanation of 1 and 2. Certain gantry and table angles
the TPS. will result in collision but these angles are not defined in
Lack of machine limitations in TPS. the TPS. So, TPS will allow this but in reality this will
4.4. Failure to recognize the impact cause collisions.
8 - Treatment 15. Evaluate delivery 3. Patient and delivery of patient immobilization and/or Non-radiation related
132 3.50 9.00 3.36 106.3 172
Planning system limitations system collision positioning aids on collision free injury 3. For large patient or a patient in an immobilization
zone. system there will be collisions at certain gantry angles.
Poor knowledge of patient location + This is due to failure to recognize the limitations of large
positioning on table. patients or immobilization devices.
I think this is more likely if the patient is treated off-line; I

3.2. Software design flaw
think it’s very unlikely that a functioning R&V system
R&V fails to record Treatment delivered “offline” and the
12 - Day N Delivery recorded by would not record a tx. If there’s no “double bookkeeping “
213 treatment due to R&V scheduling module is not Wrong dose 3.78 4.78 5.00 105.9 173
Treatment R&V (if applicable) [ie a paper chart], this can be very hard to track down. It
software bug updated (human error, carelessness,
was much more of a problem in the days of purely paper
6.1. poor training)
charts.
Wrong machine is chosen because of lack of
communication between MD and scheduler; also, MD
chooses the incorrect machine to treat a given disease
site even though a different machine could have given a
3. Setup treatment
1.1 or 1.2. Departmental policy. better dose distribution. (like Tomo can give better dose
fields (machine, 2.Incorrect or Poor
8 - Treatment 8. Poor choice by the RO distribution for a given site which MLC based IMRT
98 energy, MLC, beam selection of treatment Suboptimal treatment plan 5.00 3.67 4.33 104.8 174
Planning 8. Poor selection by the planner cannot yield and vice versa). Or, a
angle, , beamlet machine
large-breasted patient scheduled for a 6 MV only
size, etc.)
machine, whose treatment would be better on a higher
energy machine with bolus or a beam-spoiler but the
schedule is inflexible and the 6 MV treatments is used.
This results in a suboptimal plan.
3. Setup treatment
5.3. Ambiguous written directive and
fields (machine,
8 - Treatment 5. Incorrect selection of or communication.
100 energy, MLC, beam Poorly optimized plan 3.57 4.14 4.00 103.0 175
Planning beam energy Human error by the Planner
angle, , beamlet
size, etc.)
1. Entry of
10 - Plan 2. Failure to link to 2.2. Software error; Wrong or very wrong
145 demographic 3.00 8.29 4.29 103.0 176
Preparation external database 3.6 Inadequate programming dose and/or volume
information
Gather patient Treatment data corrupted before or during transfer
178 treatment A.. 2.2 Hardware failure 2.33 8.89 4.78 102.9 177
information
Everything in box 47 applies but the transfer of
information fails because of error in sequencer input or
9. Transfer
RTP export. The best situation is if the transfer fails
8 - Treatment optimized fluence to 3. Input data or file 2.2. Error in sequencer input or RTP
115 Wrong dose distribution 2.89 6.67 4.00 102.1 178 completely because the user is aware of the failure. The
Planning leaf sequencer – if corrupted at sequencer export.
worst situation is if the transfer fails partially because in
separate system
that case the user is not aware of the failure. The result is
that the patient may be treated incorrectly.
4. Prepare DRRs, Incorrect images Image guidance system does not generate Cone beam or
10 - Plan 2.2. software error
158 other localization (wrong angle, wrong Very wrong volume 2.75 8.25 4.13 101.6 179 radiographs correctly. Patients are shifted when
Preparation 3.6 Inadequate programming
imaging data divergence, etc) unnecessary.
6. Define, annotate Wrong volume (Set Software error results in a spatial offset between
Incorrect anatomy
10 - Plan anatomical info to be 2.2. software error patient at incorrect visualized images and the true coordinate system
162 visualization or 2.75 6.25 5.50 98.8 180
Preparation used in localization 3.6 Inadequate programming position. Geometrical
identification.
process miss. Failure.)
Two patients in the department with the same name. In
entering their information into the database, the operator
Errors in manual entry, most likely gets data crossed (e.g. mixes the medical record numbers
1- Patient causes: for the two patients or attaches Pt A’s digital photo to Pt
in electronic 1. Incorrect Patient ID
2 Database 8. (Human transcription error; Very wrong dose 3.78 8.11 3.78 98.4 181 B). Pt A is simulated for and treated for Pt B’s disease
database or written data
Information 5,3 (wrong data communicated to and vice versa. This is most likely if both patients have the
chart
RO data entry) same disease (e.g. both have left breast cancer). BUT- in
principle, the two patients could have different diseases
(even disease sites)
Inadequate Compromised CTV/OAR delineation with corresponding
2 5.2, 1.2 (Poor communication
quality/Incomplete errors in DRR’s. Increased systematic setup and tissue
and/or lack of documented general
Images motion errors
procedures
2. Inadequate volume
3 Poor communication )
scanned: ( e.g.
doesn’t include all ROIs
Volume needed for 5 [Basic not clear] 6., 3.4, ?? (Bad Wrong dose
needed for plan)
15 3 - CT/simulation treatment planning immobilization (uncomfortable) Poor Wrong volume 5.11 6.33 3.11 97.6 182
3. Wrong location
scanned communication with patient (patient
scanned
doesn’t understand why it is
5. Excessive patient
necessary) Lack of support from
motion during scan or
medical personnel , (e.g. MD can
other (e.g., metal)
give pt a sedative or painkiller. )
artifacts
Overly lengthy simulation session.
10 - Plan 2. Specification of 2.2. software error Software incorrectly handles a prescription or
151 2. Wrong prescription Wrong or very wrong dose 2.14 8.00 6.14 96.3 183
Preparation treatment course 3.6 Inadequate programming normalization point
10 - Plan 2. Specification of 3. Wrong course 2.2. software error
153 Wrong dose fractionation 2.43 7.00 5.71 92.6 184
Preparation treatment course scheduling etc 3.6 Inadequate programming
2.6 Inadequate assessment of
Inappropriate protocol Possible collision,
materials/tools/equipment for task
10 - Plan (viz., tolerance table, inappropriate tolerances
157 3. Delivery protocols 3.2 Inadequate design specifications 2.40 4.80 4.20 91.0 185
Preparation wrong use of allowing wrong volume or
3.6 Inadequate programming
automation) dose
LINAC “goes down” partway through treatment.
Only partial treatment
12 - Day N 2.2. Hardware failure Therapist only delivers some of the fields (e.g. one
211 Treatment delivered delivered (e.g. 3 out of Inconvenience 4.89 4.33 3.67 88.6 186
Treatment Carelessness therapist leaves for lunch, another takes over and
5 beams)
mistakenly thinks patient is finished)
Deletion: Planning done without benefit of extra imaging
2.2 (Hardware failure) Planning rushed
5. Scan made Delay in making scan
4 - Other 8. (inattention to detail)
accessible for accessible
pretreatment Delay:
30 radiation therapy Images accidentally Wrong volume 4.22 4.44 3.78 86.2 187
imaging for CTV 5.3 (Poor communications between
planning in timely deleted.
localization departments)
fashion
4.6 (inadequate personnel)
10 - Plan 2. Specification of 4. Fields not ordered 2.2. software error Software error leads to initial fields being treated the
155 Wrong dose fractionation 2.57 5.71 6.14 86.0 188
Preparation treatment course correctly (initial/boost) 3.6 Inadequate programming number of fractions prescribed for the boost
Delivery recorded in
12 - Day N Partial delivery
216 paper chart (if Human error/carelessness Wrong dose 4.89 4.44 4.11 84.9 189
Treatment incorrectly recorded.
applicable)
Bad parameters were chosen. Optimization fails because of all the causes listed in the
3.2. Software error (Wrong cost cause column.
function)
3. Optimization fails Impossible plan constraints (no
8 - Treatment (does not converge, or feasible solutions).
112 8. Run optimization Inconvenience (staff) 5.78 3.89 3.33 83.3 190
Planning gives clearly non- Inadequate search (not enough
optimal answer) iterations).
Inadequate beam technique
parameters
The location of the isocenter results in unnecessary

splitting of the fields. Main cause is
3. Setup treatment
inexperience on the part of the planner (perhaps
fields (machine, 7. Bad selection of
8 - Treatment inadequate training) – say the sim picks a poor isocenter
102 energy, MLC, beam isocenter (makes Human error by sim or planner Poorly optimized plan 4.22 4.00 4.22 80.6 191
Planning (not knowing where the PTV will really be) and an
angle, , beamlet planning hard)
inexperienced planner doesn’t realize that he can change
size, etc.)
isocenter as long as he provides information as to how to
shift to the new iso.
Therapist fills in the treatment slots in charts before they
Delivery recorded in
12 - Day N Treatment delivery are delivered. Then something happens (e.g. patient
215 paper chart (if Human error/carelessness Wrong dose 4.11 4.89 3.33 80.4 192
Treatment recorded twice doesn’t come in!) and therapist forgets to correct his
applicable)
entries.
Likely noticed during subsequent treatment fractions
Localization; (port
11 - Day 1
186 films and/or other 1. Images not taken Human error Wrong location 4.22 6.89 2.67 78.8 193
Treatment
localization devices)
There are situations where a patient would be better
treated with IMRT than with ordinary 3DCRT but because
of scheduling (patient on a non-IMRT machine) or
Human error by the Planner or MD.
3. Setup treatment insurance (insurance won’t pay for IMRT) or departmental
1. Incorrect selection of 5.2. Lack of communication between
fields (machine, policy (dept. wants to curb IMRT for logistic reasons)
8 - Treatment treatment technique. Planner and treatment Scheduler
97 energy, MLC, beam Suboptimal treatment plan 4.38 4.13 3.50 77.4 194 reasons IMRT has not been used. MD chooses the
Planning Linac based vs Tomo 1.1 or 1.2. Departmental policy
angle, beamlet size, incorrect machine to treat a given disease site even
based 8. Poor choice by the RO
etc.) though a different machine could have given a better dose
distribution. (like Tomo can give better dose distribution for
a given site which MLC based IMRT cannot yield and vice
versa).
10 - Plan 2. Specification of 1. Wrong patient or 2.2. software error Wrong or very wrong
149 2.00 7.00 4.29 75.4 195
Preparation treatment course plan 3.6 Inadequate programming dose and/or volume
Typical problem would be error writing files due to disk
Minimum: Inconvenience
space or software error. Depending on software’s validity
Saving the patient 1. Saving incomplete 2.5 User error – overrunning (staff and patient)
79 7 - RTP Anatomy 4.25 5.00 3.88 72.6 196 checking and design, resulting file can be unreadable
anatomical model model or file I/O errors software limitations2.2 Software error Maximum: Very wrong
(corrupted) or just partially read in, which might lead to
dose distribution/volumes
mistaken model of anatomy.
This can happen at two levels: Sequencer may ask user
to enter MLC limits at the commissioning level. User may
enter the wrong limits as is the case for the user level.
Sequencer may ask the user to enter the MLC limit at the
user level. At this level, suppose the user enters a limit of
10. Run leaf 6. Interdigitization limits
8 - Treatment Wrong machine configuration; 16 cm. The sequencer will generate leaf profiles that will
122 sequencing to create incorrect (Elekta, Inconvenience 4.33 3.67 3.22 65.7 197
Planning 8. wrong choice allow 16 cm of leaf motion. But hardware requirements
deliverable plan. Siemens)
may limit leaf motion to only 14 cm. Therefore, sequencer
will generate a leaf profile that results in an incorrect dose
distribution.
There could be many other situations that I do not know.
10 - Plan 7. Decide delivery 2. Unexpected changes 2.2. software error Potential table crash
165 2.00 4.25 3.25 64.5 198
Preparation ordering of fields in sequence of fields 3.6 Inadequate programming scenarios.
Wrong user input. 1. Delay or inefficient
5. Define imaging
1.2 Inadequate procedure setup. 2.
10 - Plan sequences to be
161 Wrong imaging planned 1.3 Procedure not followed Set patient at incorrect 3.80 3.80 2.40 64.2 199
Preparation used for localization
6.1 Inadequate training/orientation position. Geometrical
process.
miss. Failure.
Problem with file transfer Corrupt CT file on urgent patient requires beam definition
on the basis of orthogonal plain x-rays
Very wrong dose
5 - Transfer images 2.2 Defective materials (software or
Transfer primary File corrupted distribution
33 and other DICOM hardware) 3.89 5.78 2.33 62.7 200
(CT) data set Very wrong volume
Data 3.2 Inadequate design specifications
4. Patient “exceeds
scan diameter” and 4 2.6, 6.4, 5.2 (Equipment limitation
Volume needed for Wrong dose
volume of interest or Poor patient positioning. Failure to
16 3 - CT/simulation treatment planning Wrong location 4.33 5.44 2.67 61.9 201
volume traversed by communicate with planner when
scanned
one or more beams is problem is recognized.)
truncated.
1.2. Poor dept. policy This shouldn’t be possible with an R&V system but I’ve
Some beam(s) 2.1. No R&V seen instances of this on machines without an R&V. It’s
12 - Day N
212 Treatment delivered delivered twice in one 3.2. Poor R&V design Very wrong dose 2.56 5.67 3.44 59.7 202 most likely if therapists can “tag team” each other during a
Treatment
session Carelessness patient’s treatment session instead of waiting to trade off
jobs till that session is over.
1. Delay or inefficient
5. Define imaging
setup.
10 - Plan sequences to be 2.2. software error
160 Wrong imaging planned 2. Set patient at incorrect 2.80 3.80 2.60 59.4 203
Preparation used for localization 3.6 Inadequate programming
position. Geometrical
process.
miss. Failure.
8. Poor user choicet. Poor choice of beam sequencing requires the gantry or
1.2 Inadequate procedure collimator to rotate back and forth on itself
10 - Plan 7. Decide delivery 1. Poor choice of No effect
164 1.3 Procedure not followed 4.67 2.89 4.00 55.2 204
Preparation ordering of fields sequence Inefficient delivery
5.4. Miscommunication; Physician does not sing the hard copy or electronic chart
inattention, indicating that the plan was approved for treatment.
1.1. lack of procedure
2. Completion of
6. Not signed when 1.2 Inadequateprocedure
143 9 - Plan Approval formal prescription No effect on patient 6.78 2.00 3.00 53.3 205
appropriate 1.3 Procedure not followed
after planning
3.5. Failure to recognize the Inconvenience (staff and

1. Treatment volume limitations of the delivery system, patients)
8 - Treatment 15. Evaluate delivery
129 inappropriate for the 6.1. Inadequate training 1. Wasted time and effort, 3.71 3.43 2.71 53.0 206
Planning system limitations
delivery system Inadequate commissioning 2. Patient treatment
delayed
When you do the conversion from fluence to leaf
sequence, the software crashes; then there can be a
corrupt fluence file which will be input to the sequencer or
10. Run leaf because of the crash there can be a corrupt output file
8 - Treatment
118 sequencing to create 2. Crash in sequencer 2.2. Software or file I/O error. Inconvenience 3.22 4.67 2.11 50.9 207 from the sequencer which will be input to the TPS for
Planning
deliverable plan. dose calculation. This will result in delay or incorrect dose
calculation.
Delay because the planner will have to go through the
entire process again.
For Varian machine the collimator cannot rotate full 360
Incorrect delivery system definition in
degrees. But the plan asks for a rotation of the collimator
the TPS. .
in the forbidden region. This will be an example of nos. 1
Lack of machine limitations in TPS 1. Wasted time and effort,
8 - Treatment 15. Evaluate delivery 2. Undeliverable and 2 causes identified in the cause column.
131 Poor knowledge of patient location + 2. Patient treatment 4.11 3.00 2.78 49.0 208
Planning system limitations treatment plan 3. You want to treat the leg but you scanned the patient
positioning on table. delayed
head in first. This may result in placement of the patient
Inadequate commissioning.
on the table that does not allow access to the target for
treatment.
1.2 or 3.2 (Poor scheduling process)
CT images
Download not done in 8. (Inattention to detail)
24 3 - CT/simulation downloaded to next Inconvenience-staff 5.88 2.75 1.88 48.4 209
timely fashion 5.3 (Lack of communication)
“station”
Human error Maximum leaf speed is exceeded; maximum/minimum
10. Download 2.2. Software error gantry arc speed is exceeded. Minimum control points not
2. Incompatibility of
10 - Plan complete delivery 1.2 Inadequate procedure met. Plan is undeliverable
172 plan data with delivery Inconvenience 3.22 3.44 2.44 46.3 210
Preparation plan to delivery 1.3 Procedure not followed
capabilities
system 6.1 Inadequate training/orientation
Problem with file transfer Corrupt secondary file requires plan based on primary
data set only.
Very wrong dose
5 - Transfer images 2.2 Defective materials (software or
Transfer secondary 2. File corrupted distribution
36 and other DICOM hardware) 4.00 5.67 1.89 43.7 211
(MRI, PET) data sets Very wrong volume
Data 3.2 Inadequate design specifications
1.3, 5.3 (Lack of communication Images need to be repeated.

between auxiliary dept. and Rad
4 - Other Onc)
Inconvenience-patient
pretreatment
28 4. Scan performed a. Wrong area imaged Inconvenience-staff 4.44 3.33 2.22 34.9 212
imaging for CTV 1.2 (Lack of formal procedures.)
localization
6.1 (Inadequate staff training)
Everything in the above box applies but the transfer of

information fails because of network failure or error in
9. Transfer
transfer program. The best situation is if the transfer fails
8 - Treatment optimized fluence to 2.2. Error in transfer program,
114 2. Transfer failure Inconvenience (staff) 3.44 2.78 2.00 34.3 213 completely because the user is aware of the failure. The
Planning leaf sequencer – if 2.2. Network error. File-write error
worst situation is if the transfer fails partially because in
separate system
that case the user is not aware of the failure. The result is
that the patient may be treated incorrectly.
2.2 Defective materials (software or
hardware)
Inconvenience (patient Image files corrupted during network transfer by network
Import images into 2.3 Inadequate maintenance
53 7 - RTP Anatomy 3. File(s) corrupted and staff) 3.88 3.00 1.75 21.9 214 problem or software error. Causes inaccessible image
RTP data base 2.5 Used incorrectly
data or program crash, need to re-image patient
Inadequate storage facilities Immobilization device misplaced or “VacLoc” bag looses
vacuum leading to loss of shape.
Inadequate storage facilities and
Hardware lost poor procedures..
2- Immobilization Patient-specific {There’s nothing in the Canadian list Inconvenience (staff and
10 4.78 2.89 1.56 21.7 215
and Positioning hardware storage Hardware damaged corresponding to inadequate storage patient)
facilities}
Also – 5.2 : Lack of communications
8. (Inattention to detail)
Image set saved or
Simulation image set 4.6, 4.1 (rushed process) Inconvenience (staff and
23 3 - CT/simulation sent to treatment 3.56 2.89 1.44 18.9 216
accidentally deleted 1.2 (Inadequate backup procedures) patient)
planning

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Potential Failure Potential Causes of Failure Potential Effects of Rank Notes and Examples of Causes and Failures Compiled

step # Major Processes Step AVG O AVG S AVG D AVG RPN

6.1, 6.4 (User not familiar with

One needs to look at DVH and dose distribution on a slice

TPS is commissioned badly. Inadequate measurements;

4-D representations 6.1. Inadequate training Wrong volumes, leading

Fusion is easy to do poorly – no quantitative result to

Suppose Physician wants 95% vol. to be covered by 50

For a given disease site departmental guidelines do not

Example: Causes are same as above except that MD

Inattentiveness Severity passed on unobserved movement on one

Specify inappropriate Target volume based on MR only when it should have

Examples: Field sizes or gantry angles or indexed couch

Different scaling factors used for RO defined contours and

Dose to patient is higher or lower than MD intended. The

2. Failure to notice Example: Failure of MLC to move.

Beside dose constraints there are other parameters that

1 Procedure failures Suboptimal plan

1 (all) Procedure failure

1 (all) Procedure failure

2.5 User error

There are situations where a branching structure

Gather patient Data modified by a user or other user error

Lack of standardized procedures Marking on the immobilization device placed in incorrect

Effect: beams intersect with the wrong parts of anatomy –

MD does not communicate to the planner the desired

Human error Inappropriate scripting or plan library is used to set up a

Chances are really very slim.

Boolean combination 1. (all) Unknown software

All critical structures needed to generate an optimized

1. Incorrect patient Incorrect data base. Incorrect transfer from database to

Gantry rotation is performed automatically (e.g. acquiring

1. Incorrect/inadequate Significant isocenter positioning/treatment volume error.

In order to understand whether the leaf sequence is right

1 (all) Procedure failure

1.Incorrect More structures contoured than the software allows with

Wrong user input. Normal tissue is mistaken for a tumor resulting in

Very wrong location Inadequate checks

Human error MD prescribes BID but course is scheduled QD

Delivery recorded in Therapist is distracted – treats patient but doesn’t make

Not sure what “corrupted” means here but presumably a

Drawing strangely-shaped contours, corners, loops, and

11 - Day 1 1. Treatment not Likely to be noticed as discrepancy in record later – not

11 - Day 1 Human failure Likely to be noticed.

Examples: In one version of Varian/Varis, not terribly long

I think this is more likely if the patient is treated off-line; I

The location of the isocenter results in unnecessary

There could be many other situations that I do not know.

3.5. Failure to recognize the Inconvenience (staff and

1.3, 5.3 (Lack of communication Images need to be repeated.

Everything in the above box applies but the transfer of

Also – 5.2 : Lack of communications

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