Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

Eric Ford; Ray Gaudette; Lee Myers; Bruce Vanderver; Lilly Engineer; Richard Zellars; Danny Y. Song; John Wong; Theodore L. Deweese

Study

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

July 1, 2009

Ford E, Gaudette R, Myers L, et al. Int J Radiat Oncol Biol Phys. 2009;74(3):852-8.

View more articles from the same authors.

Failure mode and effects analysis was used to prospectively analyze an external beam radiation therapy service in order to identify potentially unsafe processes.

PubMed citation

Available at

Related Resources From the Same Author(s)

Safety strategies in an academic radiation oncology department and recommendations for action.

January 30, 2005

Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care.

March 15, 2017

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.

May 18, 2016

The impact of health system membership on patient safety initiatives.

January 9, 2008

A contemporary medicolegal analysis of outpatient medication management in chronic pain.

November 8, 2017

Incident learning in radiation oncology: a review.

August 15, 2018

U.S. Food and Drug Administration Precertification pilot program for digital health software: weighing the benefits and risks.

April 11, 2018

Cultural transformation after implementation of crew resource management: is it really possible?

July 27, 2016

Hospital responses to the Leapfrog Group in local markets.

February 20, 2008

Assessing the relationship between patient safety culture and EHR strategy.

July 20, 2016

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

January 16, 2013

Managed care penetration and other factors affecting computerized physician order entry in the ambulatory setting.

March 7, 2007

Characteristics associated with postdischarge medication errors.

August 6, 2014

Examining medical office owners and clinicians perceptions on patient safety climate.

November 7, 2018

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

June 7, 2017

How differences between manager and clinician perceptions of safety culture impact hospital processes of care.

February 14, 2018

Incomplete EHR adoption: late uptake of patient safety and cost control functions.

September 19, 2007

A system analysis of a suboptimal surgical experience.

February 4, 2009

Sleep deprivation and error in nurses who work the night shift.

February 19, 2014

A radiation oncology-specific automated trigger indicator tool for high-risk near-miss safety events.

March 4, 2020

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

November 21, 2007

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

April 30, 2014

Minimising medication errors in children.

February 25, 2009

Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.

November 8, 2006

Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.

May 25, 2011

Correlation between 24-hour predischarge opioid use and amount of opioids prescribed at hospital discharge.

December 20, 2017

Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met?

January 23, 2008

Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

September 23, 2015

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

December 22, 2010

Toward learning from patient safety reporting systems.

January 10, 2007

Underlying reasons associated with hospital readmission following surgery in the United States.

February 18, 2015

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

March 14, 2012

Description and yield of current quality and safety review in selected US academic emergency departments.

August 30, 2017

A 3-year study of medication incidents in an acute general hospital.

April 23, 2008

A human factors subsystems approach to trauma care.

August 27, 2014

Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.

February 6, 2013

Regional variations in diagnostic practices.

May 12, 2010

Interventions to reduce medication errors in adult intensive care: a systematic review.

September 26, 2012

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

October 6, 2010

Medication adverse events in the ambulatory setting: a mixed-methods analysis.

October 26, 2022

MRSA Infections.

November 7, 2007

Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.

June 27, 2012

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

Methods used to obtain pediatric patient weights, their accuracy and associated drug dosing errors in 142 simulated prehospital pediatric patient encounters.

August 25, 2021

Risk factors of missed colorectal lesions after colonoscopy.

September 6, 2017

Patient safety indicators for judging hospital performance: still not ready for prime time.

February 24, 2016

Prevalence and predictability of low-yield inpatient laboratory diagnostic tests.

September 25, 2019

A case for improving measurement of intraoperative iatrogenic injuries.

July 23, 2014

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.

February 22, 2023

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.

June 5, 2013

Flow disruptions in trauma care handoffs.

May 22, 2013

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Patient safety: the patient's role.

February 14, 2007

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

July 26, 2023

The challenges and opportunities for shared decision making highlighted by COVID-19.

August 12, 2020

Role-modeling and medical error disclosure: a national survey of trainees.

February 12, 2014

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

Applying decision science to the prioritization of healthcare-associated infection initiatives.

October 27, 2021

Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model.

April 25, 2012

Winning the battle for standardization.

November 7, 2007

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

May 22, 2013

Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.

March 13, 2019

Adverse effects of computers during bedside rounds in a critical care unit.

August 1, 2018

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

April 26, 2006

Retained lumbar catheter tip.

April 5, 2017

Dosing errors made by paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference.

July 24, 2019

Reported medication events in a paediatric emergency research network: sharing to improve patient safety.

November 28, 2012

What every graduating resident needs to know about quality improvement and patient safety: a content analysis of 26 sets of ACGME milestones.

July 18, 2018

Speaking up to reduce noise in the OR.

July 22, 2015

Inappropriate medication in a national sample of US elderly patients receiving home health care.

October 26, 2011

Consumer mobile apps for potential drug–drug interaction check: systematic review and content analysis using the Mobile App Rating Scale (MARS).

April 18, 2018

The influence of resident involvement on surgical outcomes.

January 30, 2005

Crew resource management training--clinicians' reactions and attitudes.

September 28, 2005

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

Comparison of clinical diagnoses and autopsy findings: six-year retrospective study.

October 18, 2017

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

Diagnostic error in medicine: analysis of 583 physician-reported errors.

November 18, 2009

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

April 20, 2011

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network.

April 3, 2013

Identifying potential prescribing safety indicators related to mental health disorders and medications: a systematic review.

August 14, 2019

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.

May 30, 2018

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

September 21, 2016

What is the return on investment for implementation of a crew resource management program at an academic medical center?

October 14, 2015

Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.

November 24, 2010

Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings.

October 22, 2014

Can medical record reviewers reliably identify errors and adverse events in the ED?

May 25, 2016

How should U.S. hospitals prepare for Coronavirus disease 2019 (COVID-19)?

April 8, 2020

Patients' perspectives of surgical safety: do they feel safe?

April 8, 2015

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

January 14, 2015

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

August 25, 2010

Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events.

September 21, 2011

Evidence for anchoring bias during physician decision-making.

July 12, 2023

Assessment of adverse drug events among patients in a tertiary care medical center.

November 29, 2006

Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties.

August 12, 2015

Measuring the cost of hospital adverse patient safety events.

November 10, 2010

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.

January 15, 2014

Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety.

June 9, 2021

Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues.

July 25, 2007

A prospective controlled trial of an electronic hand hygiene reminder system.

October 21, 2015

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Related Resources

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

November 15, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Breast cancer missed at screening; hindsight or mistakes?

July 26, 2023

Developing electronic clinical quality measures to assess the cancer diagnostic process.

June 21, 2023

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Using A.I. to detect breast cancer that doctors miss.

March 15, 2023

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

March 8, 2023

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

Factors impacting on patient setup analysis and error management during breast cancer radiotherapy.

November 9, 2022

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

May 4, 2022

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort.

March 16, 2022

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

December 22, 2021

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy.

November 17, 2021

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

November 17, 2021

Oncologic errors in diagnostic radiology: a 10-year analysis based on medical malpractice claims.

November 10, 2021

Racial disparities in diagnostic delay among women with breast cancer.

August 18, 2021

Breast cancer screening and overdiagnosis.

August 11, 2021

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Errors in breast imaging: how to reduce errors and promote a safety environment.

July 7, 2021

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

March 17, 2021

Algorithmic prediction of failure modes in healthcare.

January 13, 2021

WebM&M Cases

Delayed Breast Cancer Diagnosis: A False Sense of Security.

December 23, 2020

Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU.

December 9, 2020

Missed breast cancer: effects of subconscious bias and lesion characteristics.

August 5, 2020

The role of cognitive bias in breast radiology diagnostic and judgment errors.

May 27, 2020

International evaluation of an AI system for breast cancer screening.

January 29, 2020

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Medical Oncology

Radiology

Failure Mode Effects Analysis

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site