28f78144-f82f-47e3-92ad-2c3ec0cebffa1Pending0001-01-01T00:00:002000€2022-09-06T14:48:10.51189582023-02-28T11:29:38.70039480cdf0c35-810b-47c4-b0e5-b0b94a5c1c3128f78144-f82f-47e3-92ad-2c3ec0cebffa190f41ca-6aa4-45c8-926b-237d4b37b3c8Decision to treat100110001-01-01T00:00:000001-01-01T00:00:0000e7ebd2-38ca-4bd6-8cf9-934dfe83cf0c0cdf0c35-810b-47c4-b0e5-b0b94a5c1c31Suboptimal treatment decision8.33898.339c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.51190792022-10-12T15:06:05.64851616bdda13-56e6-4aa5-9bf5-f0bb7c5ffec700e7ebd2-38ca-4bd6-8cf9-934dfe83cf0c5962f87f-5155-42f3-91ea-e3c812c49589Barrier0.5499382db-a18f-4012-9d9f-ab7092367b5500e7ebd2-38ca-4bd6-8cf9-934dfe83cf0c34391759-312f-41d4-8852-80c9c32cfb24Barrier0.1d50e9d7e-66c7-46b6-b150-caea9054425c00e7ebd2-38ca-4bd6-8cf9-934dfe83cf0cc64551e2-0edc-4c9e-b810-aa551005b12cPrevention0.03ecafaac8-9062-4578-9aa0-770078f2139400e7ebd2-38ca-4bd6-8cf9-934dfe83cf0c>Incomplete documentation (previous treatments, medical conditions etc.) >Wrong information provided by the patient (e.g. due to loss of memory, incomprehension etc.) >Poor judgement (inexperience, lack of education) >Slip2022-09-06T14:48:10.51190942022-09-06T14:48:10.5119095599.7600truetruefalse0000e4fbd6cc-c7dd-47d4-a0b5-2d01d99a84d40cdf0c35-810b-47c4-b0e5-b0b94a5c1c31Physician signature in physician directive is missing13.5616a97a55bf-bd1b-4026-b6e5-f6697d5c13882022-09-06T14:48:10.514242022-10-12T15:12:53.22447156277032d-e159-436f-8641-eb93a237863ee4fbd6cc-c7dd-47d4-a0b5-2d01d99a84d4607afca5-1874-4804-884d-3632b42f6c2bPrevention0.00019dc0cec5-9952-4f28-8839-91779b95fc7ee4fbd6cc-c7dd-47d4-a0b5-2d01d99a84d4fd750f75-6038-47db-92d6-000eac72c898Barrier0.0557eac1bf-8792-4e59-b88e-be28c7be35c9e4fbd6cc-c7dd-47d4-a0b5-2d01d99a84d4Loose documents lost during transport of patient files or records2022-09-06T14:48:10.51424082022-09-06T14:48:10.5142412100falsefalsefalse0000190f41ca-6aa4-45c8-926b-237d4b37b3c828f78144-f82f-47e3-92ad-2c3ec0cebffaPatient assessment100112022-09-06T14:48:10.51190082022-09-06T14:48:10.511900910012bb967d8-2284-40a8-b78e-f8ec534b3b7828f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bFinal plan review and prescription clinical approval100180001-01-01T00:00:000001-01-01T00:00:002b893f02-449a-43bf-991a-4e81bb3b97532bb967d8-2284-40a8-b78e-f8ec534b3b78Wrong plan approved53.1454ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.52906592023-01-11T17:03:45.530618038e460d-f359-4852-8055-6ab80b0b7bfb2b893f02-449a-43bf-991a-4e81bb3b9753bdc29400-b0ae-4d5a-85b5-6fbaf351fb84Barrier0.01ba50c6f7-354e-4ecf-ac6a-7a5f9508a2ca2b893f02-449a-43bf-991a-4e81bb3b9753e9b7ece0-3158-495b-81b5-e256a5253440Prevention0.002c6c6d335-7538-4310-9721-ea732faa71ef2b893f02-449a-43bf-991a-4e81bb3b97532f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.4e63428ec-2691-4199-981e-a5e9df5b80382b893f02-449a-43bf-991a-4e81bb3b975334391759-312f-41d4-8852-80c9c32cfb24Barrier0.07f214e00f-da1b-479c-b4d0-4e221d4a633d2b893f02-449a-43bf-991a-4e81bb3b9753301bef85-d384-4b80-8345-a3392c426cffBarrier0.1471c01f3-af00-4f0d-9397-dd1acbc138ce2b893f02-449a-43bf-991a-4e81bb3b9753Isodose display confusing as not according to previous institution standarts2022-09-06T14:48:10.52906682022-09-06T14:48:10.5290669c581c49e-efe9-4395-b27c-f34a906963452b893f02-449a-43bf-991a-4e81bb3b9753This failure mode was already present in EBRT template. It has been further edited for ART case.2023-01-12T10:20:22.70173622023-02-28T10:21:34.14600266200truetruefalse0000317e8345-9f21-4eb9-99c9-f49c4152f9fd28f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bPreliminary prescription parameters, constraints & technique (i.e., physician intent)100190001-01-01T00:00:000001-01-01T00:00:00fccd9523-f358-4f15-a2b3-0ab09eef3ac1317e8345-9f21-4eb9-99c9-f49c4152f9fdIncorrect transfer of prescription5.25.645.24ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.53042732023-01-11T16:29:27.878457636182780-46b6-49e4-ae66-b0ed8963675cfccd9523-f358-4f15-a2b3-0ab09eef3ac137d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.1720af1d3-100a-467c-b721-0ee0117e2e97fccd9523-f358-4f15-a2b3-0ab09eef3ac1f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.274606f32-365a-4d0d-80e7-7071adf6df95fccd9523-f358-4f15-a2b3-0ab09eef3ac1301bef85-d384-4b80-8345-a3392c426cffBarrier0.18d919e28-abd4-4d36-aa44-53baa8686341fccd9523-f358-4f15-a2b3-0ab09eef3ac1672c54c0-dc33-42cc-af3b-6e27af99a31dBarrier0.01b1e37012-c019-4339-ba45-61dfff5a3918fccd9523-f358-4f15-a2b3-0ab09eef3ac12f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.4e43d303c-3418-426b-b2ac-377f1309d19ffccd9523-f358-4f15-a2b3-0ab09eef3ac1d4ac755f-b992-4e7d-a9ab-2f476c4b48bdPrevention0.00260000000000000077258f870-dc4e-48f1-b219-0166f476190dfccd9523-f358-4f15-a2b3-0ab09eef3ac1Concept and phases not correctly entered at initial step.2022-09-06T14:48:10.53042942022-09-06T14:48:10.53042969db33f1d-2d37-4ea1-9b9b-e1f928cf34fbfccd9523-f358-4f15-a2b3-0ab09eef3ac1This failure mode was already present in EBRT template. It has been further edited for ART case.2023-01-12T10:20:42.70205172023-02-28T10:22:15.7818057116.4800truetruefalse000031e01184-0303-45f7-b242-d9502c60e12928f78144-f82f-47e3-92ad-2c3ec0cebffa651bb09f-b2cd-4fbb-bf09-9fd4388d0c33Physics verification/approval100120001-01-01T00:00:000001-01-01T00:00:003ec8e98f-cc98-4b82-88d7-772747abb53831e01184-0303-45f7-b242-d9502c60e129Approval of a wrong plan that fails patient QA9969648488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.53382742022-10-12T15:19:37.77099211f479d1c-3093-4c02-a64c-939d25e3a7ac3ec8e98f-cc98-4b82-88d7-772747abb538f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.0593972b08-e7b9-44e3-a6fa-5a3c5ae2d0b03ec8e98f-cc98-4b82-88d7-772747abb5383bd3593d-38bc-456c-81b8-ad6b28b40f3cBarrier0.05b148a9ba-17d6-47b6-9f2b-1d706a1110e33ec8e98f-cc98-4b82-88d7-772747abb538f3f1bd74-f8ae-46e4-b9a7-0f19cc678a79Prevention0.059409ac58-3a83-4062-9b92-837ef6fd712d3ec8e98f-cc98-4b82-88d7-772747abb538>Time pressure >Unknown or obscure (black box like) behavior of patient QA equipment2022-09-06T14:48:10.53383012022-09-06T14:48:10.53383148600truetruefalse000066c7c949-34ff-47ec-a4d2-8d1cd742050331e01184-0303-45f7-b242-d9502c60e129Approval of plan with wrong technical parameters6.465.66.45.6ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-19T12:19:23.21933642023-02-28T10:27:41.8690756570e2165-9e16-4838-9b16-7c1b3551471b66c7c949-34ff-47ec-a4d2-8d1cd742050334391759-312f-41d4-8852-80c9c32cfb24Barrier0.4ef1ba586-9b45-4d12-b6e0-1e6d220bf87566c7c949-34ff-47ec-a4d2-8d1cd7420503e01fb542-e776-420b-a982-2fc8a079379cPrevention0.007000000000000002ef27be8d-ae17-496f-aaed-a063e2d1a13066c7c949-34ff-47ec-a4d2-8d1cd742050370aab6aa-693e-464e-9e30-7dc589ab742aBarrier0.037999999999999997b89aa99-0cac-4237-9da6-6d2d3a68c3a766c7c949-34ff-47ec-a4d2-8d1cd7420503Physicist plan quality check before first fraction is incomplete because of time pressure.2023-01-19T12:19:23.23706752023-01-19T12:19:23.23711629647afba-5fad-479b-b4c9-16e6604408a866c7c949-34ff-47ec-a4d2-8d1cd7420503Added to ART template2023-01-19T12:19:36.82432432023-02-28T10:23:54.435714215.0400truetruefalse0001324a2f9b-a20f-4d54-9975-2ce79045552c28f78144-f82f-47e3-92ad-2c3ec0cebffa190f41ca-6aa4-45c8-926b-237d4b37b3c8Patient consent100130001-01-01T00:00:000001-01-01T00:00:00c7c6436f-8ebd-4709-9cee-5e35b8b359e8324a2f9b-a20f-4d54-9975-2ce79045552cPatient consent lost229.329.3142dab32-eb08-407d-9b45-69cd5b5d70562022-09-06T14:48:10.51355252022-10-12T15:14:46.978374413b266aa-b91c-4d58-b153-cd80fb483833c7c6436f-8ebd-4709-9cee-5e35b8b359e8f48b7b96-c6b5-4a01-a3ae-e790ba4d4eb2Prevention0.00026bf75c06-feaa-4576-80b0-6512f703e942c7c6436f-8ebd-4709-9cee-5e35b8b359e8ef87e367-dbc5-490c-ac47-09e226da50f4Barrier0.650000000000000496979e0a-def7-45b5-b192-08f0eb2925b7c7c6436f-8ebd-4709-9cee-5e35b8b359e8>Loose documents lost during transport of patient files or records2022-09-06T14:48:10.51355332022-09-06T14:48:10.513553537.200falsefalsefalse000037831436-3059-4905-8283-096dc410466828f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Treatment delivery1002060001-01-01T00:00:000001-01-01T00:00:0015d6df8c-e5c1-421c-9deb-b36e0f02fb5d37831436-3059-4905-8283-096dc4104668Wrong MLC movement18858c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53586552022-10-12T15:08:55.35204640cc95d9a-41d4-4115-a8ac-cb565172a44415d6df8c-e5c1-421c-9deb-b36e0f02fb5d2b5c6b5c-6a7c-4a60-abce-03aa6c5b14b2Prevention0.0023fea2453-c941-4260-9d8b-2afe7c94746915d6df8c-e5c1-421c-9deb-b36e0f02fb5d68818497-3417-4c40-959a-6195e6e70f40Barrier0.2df13d09a-f44b-4cb3-9ea6-858689ca969315d6df8c-e5c1-421c-9deb-b36e0f02fb5da7c56c23-e776-4749-a044-8dba4a717804Barrier0.1f8b334c8-d222-448e-9bbe-cc042671361515d6df8c-e5c1-421c-9deb-b36e0f02fb5d59e8cc97-846e-457e-ae57-c381aa4169ccPrevention0.05cdc705af-b7ce-4e39-b098-2fe5b43ce33715d6df8c-e5c1-421c-9deb-b36e0f02fb5d>MLC wear down, >LINAC miscalibration (e.g. because calibration is not performed regulaly)2022-09-06T14:48:10.53586632022-09-06T14:48:10.53586646400truetruefalse000083235cfb-47ac-4c4a-a335-cef9e2b1f62037831436-3059-4905-8283-096dc4104668Incomplete treatment delivery1110510142dab32-eb08-407d-9b45-69cd5b5d70562022-09-06T14:48:10.54034262022-10-11T14:20:04.080845622b5d6a9-e59c-493c-a2d9-4f2f88bd675283235cfb-47ac-4c4a-a335-cef9e2b1f62059e8cc97-846e-457e-ae57-c381aa4169ccPrevention0.0529ddf106-3070-438d-9b73-09d74ba1e57f83235cfb-47ac-4c4a-a335-cef9e2b1f6205bb586d7-2f20-427f-af49-ba83ac6f81d3Prevention0.002a9b815a8-d2e6-4b60-8642-2aa2d357d40183235cfb-47ac-4c4a-a335-cef9e2b1f6208d55b2f4-1dc2-45d2-b432-ac6e37b32af3Barrier1785d6b14-8975-4a23-b8ef-f195838e3eda83235cfb-47ac-4c4a-a335-cef9e2b1f620>Malfunctioning of LINAC system>Black out2022-09-06T14:48:10.54034382022-09-06T14:48:10.54034391000falsefalsefalse0000beb63f71-38c4-41df-848c-cf3bf7b3223637831436-3059-4905-8283-096dc4104668Relevant patient movement after IGRT87484c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.54106392022-10-12T15:08:46.13614670b8d2cfe-6311-4183-b91c-d64fdf806d22beb63f71-38c4-41df-848c-cf3bf7b32236f39806fd-c182-4310-815b-35d17c55c660Barrier0.0173b5a989-15d1-4d99-b110-390f82e494c7beb63f71-38c4-41df-848c-cf3bf7b322368b13dd0d-39c2-412b-a0b5-4cafcc314a51Prevention0.02d53fc52a-5b72-4462-b56a-5db0533ec0a7beb63f71-38c4-41df-848c-cf3bf7b32236f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.2b3f8730c-09ce-42d3-92aa-505655594e5cbeb63f71-38c4-41df-848c-cf3bf7b32236>Patient non-compliance (patient not following instructions); >Couch movement can transfer momentum to patient;2022-09-06T14:48:10.54106492022-09-06T14:48:10.541065122400truetruefalse0000ec15f756-65f2-483c-b083-22930e2413aa37831436-3059-4905-8283-096dc4104668Wrong LINAC output (with dose deviation>3%)3933348488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.5351932022-10-12T15:16:56.8119724216a87ad-ca1a-4643-81d7-97a3196ecaf8ec15f756-65f2-483c-b083-22930e2413aa06104b10-1496-42ca-9a63-5578a6915e4cPrevention0.00052de703a6-10e8-44ab-beb1-a06975286eeaec15f756-65f2-483c-b083-22930e2413aade2769a1-1c95-4797-9d81-78e2df756e61Barrier0.0056b2cd4bf-0495-4bb6-9e71-2470ddc8bdd5ec15f756-65f2-483c-b083-22930e2413aac05dc000-a95e-48c3-a9e8-5ea37b227247Prevention0.0058e5b5659-dc6a-4c4d-8796-ddc30a6cf169ec15f756-65f2-483c-b083-22930e2413aae8736119-75c4-4b08-b619-fc75a3a8812ePrevention0.01ed66a11e-3553-45b6-8414-d805a40ee6d1ec15f756-65f2-483c-b083-22930e2413aaHardware malfunctioning; limited LINAC stability; change in environmental parameters in treatment room (T,P,H)2022-09-06T14:48:10.53519382022-09-06T14:48:10.53519398100truefalsetrue0000384bcc42-75e1-45f0-b18c-34a80f82083b28f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfContrast administration101.320001-01-01T00:00:000001-01-01T00:00:00b25544f3-e43c-4684-99a8-4f5cd0964a39384bcc42-75e1-45f0-b18c-34a80f82083bAnaphylaxis295253e9fd197-652a-4de9-ad47-37aa9c3d67402022-09-06T14:48:10.51560692022-09-12T15:00:08.80486979902dd3d-cb96-4b97-a8bf-b8edb0d54de7b25544f3-e43c-4684-99a8-4f5cd0964a39417a2ec5-d571-4566-bb27-94c4b6c34386Barrier0.029ded0fe8-6467-49df-bc90-280bf85b2b8bb25544f3-e43c-4684-99a8-4f5cd0964a39bcb61be6-aa5c-42b7-a971-6c7174373fc7Prevention0.000259975471-b782-47a9-a37c-23ed18cd7be5b25544f3-e43c-4684-99a8-4f5cd0964a39Unknown or undocumented immune response to contrast agent2022-09-06T14:48:10.51560822022-09-06T14:48:10.5156083e4b5f597-73fe-48e6-a4a8-3887659ae5acb25544f3-e43c-4684-99a8-4f5cd0964a39Not relevant for radiation protection2022-09-06T14:48:10.5162782022-09-06T14:48:10.51627829000falsefalsefalse0000d85caf28-3f32-4861-ba78-baff7f3e0613384bcc42-75e1-45f0-b18c-34a80f82083bExtravasation 43104103e9fd197-652a-4de9-ad47-37aa9c3d67402022-09-06T14:48:10.51628492022-10-05T09:54:38.654526987509af7-66d7-48ae-8916-f07b980e4a11d85caf28-3f32-4861-ba78-baff7f3e06137224f406-e94b-43fc-b070-2ac69ccd1339Barrier1e7729b2d-6e4d-4486-bb79-2e7aca555faed85caf28-3f32-4861-ba78-baff7f3e06133a707fde-e97a-4fc6-93c5-0af4c68d9d5cPrevention0.00192d7466c-b8ab-4faf-8b51-e0fb55497645d85caf28-3f32-4861-ba78-baff7f3e0613>Poor puncture technique >Movement of patient2022-09-06T14:48:10.5162862022-09-06T14:48:10.516286168bb67ae-38dc-4deb-8061-f44462b706cad85caf28-3f32-4861-ba78-baff7f3e0613Not relevant for radiation protection2022-09-06T14:48:10.51695182022-09-06T14:48:10.516951912000falsefalsefalse00003c5829d2-fb6c-4299-ad75-28a0632ed31728f78144-f82f-47e3-92ad-2c3ec0cebffa190f41ca-6aa4-45c8-926b-237d4b37b3c8Patient education100120001-01-01T00:00:000001-01-01T00:00:0046382090-2657-477b-bbac-1c2e2f988e8a3c5829d2-fb6c-4299-ad75-28a0632ed317Poor patient education658.1768.17ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.51284872022-10-12T15:11:39.776329607498314-b33f-4c37-81e2-ac7fae7b2c9f46382090-2657-477b-bbac-1c2e2f988e8a0cd4c0fe-d40b-4a25-a253-17aa9830a994Prevention0.0058acb80e9-5d02-4c43-adb3-f08715cab7dd46382090-2657-477b-bbac-1c2e2f988e8a38450f25-98d3-4a74-8595-9f99f63a14deBarrier0.25b57586e6-7176-4c02-9d9e-3d507d8c5f5746382090-2657-477b-bbac-1c2e2f988e8a>Time factors>Stress>Lack of skill>Lack of training>Treatment complexity>clinical workload2022-09-06T14:48:10.51285062022-09-06T14:48:10.5128507245.100falsefalsefalse00003c8fe4b4-76c8-4679-ab66-fb73d6a2750d28f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfVerification of patient ID1001.310001-01-01T00:00:000001-01-01T00:00:00524f3cf6-c433-49eb-b767-9648ac009dc43c8fe4b4-76c8-4679-ab66-fb73d6a2750dPatient mix-up21022271ae1273-b59d-45da-a1a7-573718fbe6c62022-09-06T14:48:10.51492322022-10-12T15:03:24.980765832ed4916-f301-4b23-9fe1-3816c2e3b8f4524f3cf6-c433-49eb-b767-9648ac009dc41351db22-bcb1-42d0-821a-b34ad5698946Barrier0.0023707c856-d734-4803-8576-9886fc5ba890524f3cf6-c433-49eb-b767-9648ac009dc48d955d14-8bb4-4b04-9dbd-e143aea6a57fPrevention0.000288848ea6-a0ae-4a30-a032-d1e3ab458405524f3cf6-c433-49eb-b767-9648ac009dc4a07d24fc-8e17-49fa-b21c-7472331674d3Prevention0.058e2afdef-ac1c-44cc-b291-add65c101921524f3cf6-c433-49eb-b767-9648ac009dc45d9a25d7-974f-467f-bb48-acc443d6f01fPrevention0.01651a2031-7fe4-44ef-b149-687ae80c1eb6524f3cf6-c433-49eb-b767-9648ac009dc4Insufficient data (e.g. photo) available to recognize the patient>staff problem>clinical workload2022-09-06T14:48:10.51492412022-09-06T14:48:10.51492424000truefalsetrue00003daedfac-fa43-47ab-980d-5902c532bf2628f78144-f82f-47e3-92ad-2c3ec0cebffaTreatment100152022-09-06T14:48:10.53450552022-10-12T13:41:00.926443820-1001-203f39cc3f-668a-494c-9e07-dc7d9f2cd9fd28f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfAcquisition of other images (MR, PET...)30150001-01-01T00:00:000001-01-01T00:00:006ad8aa86-74ed-4bab-8531-4bfa211c954a3f39cc3f-668a-494c-9e07-dc7d9f2cd9fdWrong interpretation of non-CT imaging studies78474c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.52039782022-10-12T15:06:27.2642725bfc29818-32d2-4578-ab1d-0e9a3b3472266ad8aa86-74ed-4bab-8531-4bfa211c954af6d553a0-3944-4245-9ab5-90fa7ad5ecbePrevention0.01fd34fac6-bc37-4c2e-83ba-2c2613f47dbc6ad8aa86-74ed-4bab-8531-4bfa211c954a0667b26f-9080-40da-8431-8bf732be42ecBarrier0.0190f06d30-4f82-4ec0-8858-5b5a0e03b6d06ad8aa86-74ed-4bab-8531-4bfa211c954a>Lack of training or skills >Lack of experience>Poor communication>Mix-up of PET radiopharmakon>heavy workload2022-09-06T14:48:10.52039862022-09-06T14:48:10.520398722400falsefalsefalse0000417ea27d-1749-4617-84b4-3cb88bd5fb0e28f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Gating/breath hold specific operations20140001-01-01T00:00:000001-01-01T00:00:00dd00bd55-2ec9-461c-b042-87c9a38b4b94417ea27d-1749-4617-84b4-3cb88bd5fb0ePatient cannot follow breathing commands48343c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53936522022-10-12T15:08:37.10884416867f304-594a-4c7d-b97e-bfaca49ab676dd00bd55-2ec9-461c-b042-87c9a38b4b941c02ed82-87af-4a37-99a1-ee0e02818076Barrier0.005a263f00d-19e3-4b66-a643-4a5b7afebdc0dd00bd55-2ec9-461c-b042-87c9a38b4b9432c40d0e-8c69-4a0c-ba85-8a1a1f0945a1Prevention0.001b4abbf60-e283-48c0-8253-82f697e0544fdd00bd55-2ec9-461c-b042-87c9a38b4b94f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.25567dcf8-7d5b-48f8-bd3a-140a15904b8add00bd55-2ec9-461c-b042-87c9a38b4b94>Lack of training, or ineffective training >Poor judgment (e.g., failure to carry out quality control on a patient due to time limitation)2022-09-06T14:48:10.53936632022-09-06T14:48:10.53936649600truetruefalse00005790f225-4759-4b83-aaf3-a152592e761e28f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfPatient positioning1001.330001-01-01T00:00:000001-01-01T00:00:0099a13a24-1ad9-4a7b-88f1-dc8832142c8c5790f225-4759-4b83-aaf3-a152592e761eSuboptimal positioning96696ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.5176372022-10-12T15:11:48.94428394f75330c-c557-4326-a648-485a741a075f99a13a24-1ad9-4a7b-88f1-dc8832142c8c57007e0f-5942-4464-93f4-ceebc42bbd0fBarrier0.0550234e0f-bbbd-441e-b737-8a210942d59b99a13a24-1ad9-4a7b-88f1-dc8832142c8c2d74e68a-a8c8-460c-98d1-183754e75517Prevention0.056883bee8-34ec-4e57-98b2-0a08fb71836799a13a24-1ad9-4a7b-88f1-dc8832142c8c>Pain caused by optimal position >Poor judgement2022-09-06T14:48:10.51763782022-09-06T14:48:10.517637932400falsefalsefalse000059b65725-cedd-4dc5-a25f-e80c350ab6cf28f78144-f82f-47e3-92ad-2c3ec0cebffaImaging for RT planning100122022-09-06T14:48:10.51491942022-09-06T14:48:10.514919510-1001-1,364d3c35e-5aae-4a36-bed5-cdb43efe7eeb28f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Image-guided verification1002030001-01-01T00:00:000001-01-01T00:00:007d070b52-971b-47f4-8526-5be83994eb4b64d3c35e-5aae-4a36-bed5-cdb43efe7eebOffline review of images is not performed4.35.25.44.35.4ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-12T11:56:55.95105122023-02-28T09:52:28.389073653750ab4-e154-4a2f-89b7-be1321502e2e7d070b52-971b-47f4-8526-5be83994eb4b348b8d10-0230-4a12-aec4-a034d7ad3f40Prevention0.001362d8cee0-4b88-411a-b545-53aa6c3526587d070b52-971b-47f4-8526-5be83994eb4ba333bc18-aa17-4ea4-b570-58da80660436Barrier0.032000000000000015303a79e4-e038-418d-9008-4caebf390c4d7d070b52-971b-47f4-8526-5be83994eb4bLack of automation; lack of attention due to time pressure2023-01-12T11:56:55.9563442023-01-12T11:56:55.95634546b7863c5-9857-4b40-b340-c7c2e8dff8a47d070b52-971b-47f4-8526-5be83994eb4bAdded to ART template2023-01-12T11:57:05.73661962023-02-28T10:28:35.5048042120.7400falsefalsefalse00028f5bfde5-d93d-443b-bb08-d36235e07dc464d3c35e-5aae-4a36-bed5-cdb43efe7eebWrong couch shift7749.164c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53730472022-10-12T15:08:29.25001480d3fd22a-a42e-4646-a2f4-948b97ae2fe58f5bfde5-d93d-443b-bb08-d36235e07dc47a196970-a5e4-42f0-b8e7-8798d738987bPrevention0.257a8a4bc-dc42-4493-89cc-fe3a094a4a3f8f5bfde5-d93d-443b-bb08-d36235e07dc47518fd1c-2d2d-4836-a5ac-2dd726193b81Barrier0.0163179301-97b5-41de-a1ed-d220d986abd88f5bfde5-d93d-443b-bb08-d36235e07dc4f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.28f9278a7-fba3-450f-9b4e-9b5abc5144098f5bfde5-d93d-443b-bb08-d36235e07dc459e8cc97-846e-457e-ae57-c381aa4169ccPrevention0.05588d5256-0028-4082-80ac-07dac5621f3e8f5bfde5-d93d-443b-bb08-d36235e07dc4Wrong gain factor2022-09-06T14:48:10.53730572022-09-06T14:48:10.537305819600truetruefalse0000a57033c0-dfaf-4451-85a5-f44380cd746064d3c35e-5aae-4a36-bed5-cdb43efe7eebIndependent image check is not performed45.45.645.6ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-12T12:00:10.65881932023-02-28T10:31:18.58843015bb4e955-c726-4450-912d-bbce8050139aa57033c0-dfaf-4451-85a5-f44380cd746088ad2cf5-c9cb-4e61-a331-cd1097fd6b90Barrier0.03799999999999999f6947d5b-b77a-42c3-99f1-6b44a6f1e1c1a57033c0-dfaf-4451-85a5-f44380cd7460b351f0c4-0072-4559-b21d-be326308c400Prevention0.0016e8e88ea-73a9-4423-9de5-1f008e6717e2a57033c0-dfaf-4451-85a5-f44380cd7460Lack of attention due to time pressure2023-01-12T12:00:10.66414072023-01-12T12:00:10.6641422ac3d7108-d5e7-4502-9b00-88f29920b211a57033c0-dfaf-4451-85a5-f44380cd7460Added to ART template2023-01-12T12:00:38.62583312023-02-28T10:30:06.1748354120.9600falsefalsefalse0003651bb09f-b2cd-4fbb-bf09-9fd4388d0c3328f78144-f82f-47e3-92ad-2c3ec0cebffaPretreatment review and verification100142022-09-06T14:48:10.53110172022-09-06T14:48:10.531101810016f9426e5-68e3-4e5d-b1f5-d7380fe533e728f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfPrimary image acquisition (CT)100140001-01-01T00:00:000001-01-01T00:00:0097b9879d-6f31-4256-b90d-a01f52e64f976f9426e5-68e3-4e5d-b1f5-d7380fe533e7Wrong reconstruction of Hounsfield units26929ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.51695782022-10-12T15:11:57.22308115b655536-e4fe-4551-b5c5-8492c8192d5997b9879d-6f31-4256-b90d-a01f52e64f97eccb6393-1446-4f65-8688-bd704c0f3e4ePrevention0.00028c1af1ce-432f-480b-826b-a78b25bee1da97b9879d-6f31-4256-b90d-a01f52e64f97183ace37-3bf6-40e2-a93a-1383b1825b1aPrevention0.058c3e7b73-79b0-45d7-804d-d5275d22ba2997b9879d-6f31-4256-b90d-a01f52e64f97a7c56c23-e776-4749-a044-8dba4a717804Barrier0.2db78fdad-6299-42b2-a71a-22e0981737d797b9879d-6f31-4256-b90d-a01f52e64f9747328b8b-60d6-4ce8-b6ea-295350f0aeabBarrier0.50ae873fd-6956-4fd1-9104-337d85c3cfd197b9879d-6f31-4256-b90d-a01f52e64f97>Malfunctioning detectors>Detector Miscalibration>Poor algorithm performance proximal to high density materials leading to artifacts>CT calibration phantom inconvenience>wrong calibration procedure>insufficient staff education2022-09-06T14:48:10.51695862022-09-06T14:48:10.516958810800truetruetrue000077359ecf-575f-47bf-952c-0f8dc1f9d48628f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Verification of patient ID1002010001-01-01T00:00:000001-01-01T00:00:0063deab50-3ee6-43bd-b747-d12e7b55192d77359ecf-575f-47bf-952c-0f8dc1f9d486Patient mix-up41054571ae1273-b59d-45da-a1a7-573718fbe6c62022-09-06T14:48:10.53450982022-10-12T15:03:08.98154633f9fb54a-6781-477a-be79-44d6f25f918f63deab50-3ee6-43bd-b747-d12e7b55192d5d9a25d7-974f-467f-bb48-acc443d6f01fPrevention0.001435fba7a-173b-46d2-9a89-23827e698c2a63deab50-3ee6-43bd-b747-d12e7b55192dbe1c1968-ab8f-48d4-993b-c35f1fac1998Barrier0.027e605b5e-32f9-4b03-8cc9-92ea70ac4c4263deab50-3ee6-43bd-b747-d12e7b55192d927d5802-f14b-4a2f-857a-3b3e07bf5013Prevention0.0018352d5cb-a216-4f8f-9f66-3507f96973fb63deab50-3ee6-43bd-b747-d12e7b55192da07d24fc-8e17-49fa-b21c-7472331674d3Prevention0.05263b98cb-4e94-4fe2-804a-5feac6234e0563deab50-3ee6-43bd-b747-d12e7b55192d>Failure to execute the planned action (Stereotype take-over/faulty triggering; >Patient-related circumstances (misleading representation; Cognitive performance issues; Non-compliance; Language issues and comprehension)2022-09-06T14:48:10.53451062022-09-06T14:48:10.534510720000truefalsetrue00007e6f3f44-17ab-4e8b-a9ea-34f96d77a30328f78144-f82f-47e3-92ad-2c3ec0cebffa651bb09f-b2cd-4fbb-bf09-9fd4388d0c33Patient condition verfication100132022-10-12T13:37:46.88510072022-10-12T13:37:46.8851024fc6a497c-5fc9-435c-9d17-713a6988e4417e6f3f44-17ab-4e8b-a9ea-34f96d77a303Changes in patient medical condition (weight loss, dental restoration...) not timely communicated98393c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.54174892022-10-12T15:08:18.4377027c4a890f-83c1-45aa-857a-f86893be0e5dfc6a497c-5fc9-435c-9d17-713a6988e4418cc822ea-c9f2-4657-b062-187f47c33235Prevention0.05a9512645-a512-4d81-a89f-413b61780354fc6a497c-5fc9-435c-9d17-713a6988e44142895bef-033c-4e12-b03f-e64b6830455bBarrier0.005bc3df3cc-1f6d-43b5-abe0-2c890099c5aefc6a497c-5fc9-435c-9d17-713a6988e44193d46a1a-e7b6-4e9c-8c91-0a9076ae3630Prevention0.1e4ab2702-ca11-41b6-bb2f-ab27444ce0a5fc6a497c-5fc9-435c-9d17-713a6988e441>Poor communication2022-09-06T14:48:10.54174972022-09-06T14:48:10.541749821600truefalsetrue000080650fad-2d5c-4c79-8228-ac9b89f2155228f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bDelineation of target(s)100130001-01-01T00:00:000001-01-01T00:00:0029848146-87c2-4ffe-811b-fb3f7428eb4780650fad-2d5c-4c79-8228-ac9b89f21552Too much healthy tissue included into target volumes (due to PTV expansion)798.1778.1748488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.52490612022-10-12T15:20:20.705478139b71971-3501-41f4-a87f-49e618ae4e0229848146-87c2-4ffe-811b-fb3f7428eb47301bef85-d384-4b80-8345-a3392c426cffBarrier0.148a0c0f7-916d-44de-bfc9-5800aa3992d129848146-87c2-4ffe-811b-fb3f7428eb4739f210e7-8ed4-4af9-adb1-be4e1e6894d9Barrier0.255325482d-5a1c-4394-8619-316da722efab29848146-87c2-4ffe-811b-fb3f7428eb4737d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.1734aa353-1cbb-40c6-961f-5e444463f40f29848146-87c2-4ffe-811b-fb3f7428eb47a8cca3bb-aa80-4251-976b-146e9699dc30Prevention0.01b75c5c50-3a42-4210-a4ae-e51d4a80155a29848146-87c2-4ffe-811b-fb3f7428eb47ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.1b9278af2-853a-47b0-81ef-88c8bf2f464129848146-87c2-4ffe-811b-fb3f7428eb47>Lack of training or skills, inexperience, incomplete documentation of patient records, poor communication, poor judgement2022-09-06T14:48:10.52490782022-09-06T14:48:10.5249079514.7100truetruefalse000040e400ab-12f1-4eb6-ac52-b30fbce7777680650fad-2d5c-4c79-8228-ac9b89f21552Wrong target delineated (e.g. wrong metastasis, wrong site)61096971ae1273-b59d-45da-a1a7-573718fbe6c62022-09-06T14:48:10.5242112022-10-12T15:03:43.01627780574887c-8b19-4268-9002-4dac433d69e940e400ab-12f1-4eb6-ac52-b30fbce77776ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.0543ed2736-a3be-4910-ab63-9539fba52cc340e400ab-12f1-4eb6-ac52-b30fbce7777637d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.0552e92a8d-472f-40a9-addd-bdb12952a57240e400ab-12f1-4eb6-ac52-b30fbce7777605cbc796-914e-4a78-baf1-50c008c77204Prevention0.005f950eefa-a421-4514-a6c3-9b455e14d3cf40e400ab-12f1-4eb6-ac52-b30fbce7777696bd9989-a90f-4242-b5e0-c64cbc350b4fBarrier0.508c40a33-0fd5-4374-bf52-8ad2b4041e4a40e400ab-12f1-4eb6-ac52-b30fbce77776>Lack of training or skills (see comment about skills above), inexperience; >incomplete documentation of patient records >Poor communication 2022-09-06T14:48:10.52421212022-09-06T14:48:10.524212354000truetruefalse0000f9d9f03e-b527-4e60-9e8e-ead10b2e36d280650fad-2d5c-4c79-8228-ac9b89f21552Poor coverage of target delineation(s)7997948488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.5255872022-10-12T15:10:07.254049323b76da-804b-412b-a4a4-3ab252c935bef9d9f03e-b527-4e60-9e8e-ead10b2e36d2ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.057f5e154c-641f-4fba-a586-fde92057b0fdf9d9f03e-b527-4e60-9e8e-ead10b2e36d24dcaffea-49af-4279-8bf1-b6af3be07559Prevention0.01c092972d-a3ae-46df-9ab8-c88d76532198f9d9f03e-b527-4e60-9e8e-ead10b2e36d237d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.05c66d4d6d-3c3b-4e18-b7d1-f992f689fe67f9d9f03e-b527-4e60-9e8e-ead10b2e36d24da9c2fe-eed7-417b-af43-ef4cf658c278Barrier0.5f74f63f4-242c-4b97-ad4a-ae80433af108f9d9f03e-b527-4e60-9e8e-ead10b2e36d2>Incomplete documentation of patient records, >Poor communication >Poor judgement 2022-09-06T14:48:10.52558782022-09-06T14:48:10.52558856700truetruefalse00008eb8a0b9-0d79-4491-82ad-a8e096cef58628f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Plan information transfer to treatment unit1002020001-01-01T00:00:000001-01-01T00:00:005b79d863-bdda-4c0e-ae05-947235a9f3118eb8a0b9-0d79-4491-82ad-a8e096cef586Plan not finalized in time22222142dab32-eb08-407d-9b45-69cd5b5d70562022-09-06T14:48:10.54252192022-10-05T13:16:44.4809190fa7f6b2-364d-462a-9eff-d6e5f8df98495b79d863-bdda-4c0e-ae05-947235a9f3119dd6e96b-8b47-4105-8bce-98c58bb41106Prevention0.0002f2df7567-c281-498b-ac64-94439d2982c55b79d863-bdda-4c0e-ae05-947235a9f311187a7a75-6621-47da-9eb8-2391a22487fbBarrier0.002d048ad7d-392b-417e-bdb9-ab3e3e2e18b25b79d863-bdda-4c0e-ae05-947235a9f311>Plan forgotten in progress; >Lack of timeliness 2022-09-06T14:48:10.54252272022-09-06T14:48:10.5425228800falsefalsefalse000097fb09bc-3c2f-402a-bcaa-1b23d336bfbd28f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bDelineation of organs-at-risk100140001-01-01T00:00:000001-01-01T00:00:005dfbe4c7-75bf-4587-924b-c709fbf0bd1f97fb09bc-3c2f-402a-bcaa-1b23d336bfbdOrgan-at-risk not delineated71097971ae1273-b59d-45da-a1a7-573718fbe6c62022-09-06T14:48:10.52626652022-10-12T15:03:49.85926980932a5d6-4cd8-42a8-bb92-b43be5d95d335dfbe4c7-75bf-4587-924b-c709fbf0bd1fe1b272ad-c143-4cd9-a31f-37dcfd3e43a6Prevention0.0190933981-28c3-4acd-9cae-652457b992cf5dfbe4c7-75bf-4587-924b-c709fbf0bd1fea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.19df27f47-c2db-421d-be3f-10239fcaba925dfbe4c7-75bf-4587-924b-c709fbf0bd1f9687c2e2-4ab3-4ffa-9684-be95c008dc8cPrevention0.02f9008383-85cf-40bc-8fbd-a8164561dd405dfbe4c7-75bf-4587-924b-c709fbf0bd1f6e2f32d4-eebb-470a-882f-13e8bf6e2651Barrier0.5fa3e874a-3189-4513-a370-5282951399b35dfbe4c7-75bf-4587-924b-c709fbf0bd1f2f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.4fcc6e022-4917-4589-9ce7-ee34d10bdee25dfbe4c7-75bf-4587-924b-c709fbf0bd1f301bef85-d384-4b80-8345-a3392c426cffBarrier0.1ff73d23d-a51b-467c-a105-252e1750ec895dfbe4c7-75bf-4587-924b-c709fbf0bd1f37d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.162735d45-5ea3-45b4-b5f5-8270530b019a5dfbe4c7-75bf-4587-924b-c709fbf0bd1f>Poor judgement, >slip causing physical error >Failure to select the correct rule (SOP, guidelines, process descriptions,...) to address problem2022-09-06T14:48:10.52626732022-09-06T14:48:10.526267563000truetruetrue0000a3d884d5-0bb1-42e0-9050-3c66fc294fbf28f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bDose distribution calculation100170001-01-01T00:00:000001-01-01T00:00:002bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9a3d884d5-0bb1-42e0-9050-3c66fc294fbfDose from a previous treatment is not taken into account74.4676a97a55bf-bd1b-4026-b6e5-f6697d5c13882022-09-06T14:48:10.52769852023-02-28T10:13:46.56495790da4c448-59b3-4831-bdf9-d2295a439cef2bdf02a2-8a7e-4502-94f0-dab8eb7bd3e92f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.43cdf5238-3280-45e2-b2ec-fb623f4fd23d2bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.151129d71-4609-4419-b5ca-1d41320a9b902bdf02a2-8a7e-4502-94f0-dab8eb7bd3e901ea5c18-f776-4764-aafd-7c60999c2e1bBarrier0.0554981e3e-6daa-4b7e-be3e-727837d14c292bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9301bef85-d384-4b80-8345-a3392c426cffBarrier0.15b37067c-ffea-4274-b13c-99fdc498a6392bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9ccd7659a-5d28-4b88-85b6-97512161320cPrevention0.01e5e6f71e-3efb-4e99-872d-804a23cb98a32bdf02a2-8a7e-4502-94f0-dab8eb7bd3e94ec30fa9-b472-41f3-9a32-87a85a435be2Barrier0.1702547b3-96c0-48ec-bddd-73143f7bf7342bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9Option for automated dose overlap are not available in ART TPS2022-09-06T14:48:10.52769952022-09-06T14:48:10.527699648c7e3f0-b895-41f8-ac75-66d58864c45a2bdf02a2-8a7e-4502-94f0-dab8eb7bd3e9Failure mode specific to this template2023-01-12T10:19:51.76041612023-02-28T10:15:27.0492821184.800truetruefalse000099fc5c42-1612-4a97-9c2c-d53e8a108308a3d884d5-0bb1-42e0-9050-3c66fc294fbfWrong dose calculation2.678102.6710c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812023-02-28T10:17:53.12030672023-02-28T10:17:53.12032745c7d2963-0b6b-48d0-a149-0fac6bae00e399fc5c42-1612-4a97-9c2c-d53e8a108308ea1f64a6-e1a2-4d0f-aa75-30bf9cd25f9eBarrier0.16c658898-f2ec-478c-bac1-82c3c8e824c299fc5c42-1612-4a97-9c2c-d53e8a1083082f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.46e226fff-4a03-4815-8cf8-90a2bd52882599fc5c42-1612-4a97-9c2c-d53e8a108308eb091bf1-9364-47a1-b829-7527333d10b2Barrier0.05810c2c86-b65a-45fb-9d19-e5a3ccba727f99fc5c42-1612-4a97-9c2c-d53e8a108308a7c56c23-e776-4749-a044-8dba4a717804Barrier0.1c57503ba-9681-4643-8442-cbed4842c60b99fc5c42-1612-4a97-9c2c-d53e8a108308ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.1e34cf5cc-5d16-4dad-ab78-396195837e8799fc5c42-1612-4a97-9c2c-d53e8a10830870b68ae8-4630-4f57-9c82-75efd8ae93b1Barrier1ec7666e4-5922-490c-9835-ab3d0bbf7ac599fc5c42-1612-4a97-9c2c-d53e8a108308301bef85-d384-4b80-8345-a3392c426cffBarrier0.1f2acdd32-761f-478e-9f66-79969497d8a999fc5c42-1612-4a97-9c2c-d53e8a1083080c21a871-a480-4691-ba3c-3374139e78eaPrevention0.000401112de295-80b2-4074-90a9-3facb18d641499fc5c42-1612-4a97-9c2c-d53e8a108308>Poor registration/fusion of imaging data sets >No available imaging studies of old treatment plan leads to poor estimation >Dose deviation on reconstructed plan from original plan2023-02-28T10:17:53.13160222023-02-28T10:17:53.131621213.600truetruefalse0001a3eb77c6-0cc1-4c75-8a64-10157b81ded828f78144-f82f-47e3-92ad-2c3ec0cebffa651bb09f-b2cd-4fbb-bf09-9fd4388d0c33Plan data transfer to treatment unit100110001-01-01T00:00:000001-01-01T00:00:00112856f5-42eb-463d-9629-299fdbd23bc1a3eb77c6-0cc1-4c75-8a64-10157b81ded8Wrong (number of) appointments48949c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53314662022-10-12T15:07:54.56824456169070a-a8e0-4037-a810-1e202a8f3333112856f5-42eb-463d-9629-299fdbd23bc1f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.16f604d65-3d95-4ab7-8e7e-7694fe49212e112856f5-42eb-463d-9629-299fdbd23bc11193d01b-03a3-4abc-ba0b-7c8819c6ef2fBarrier0.5c601feb9-e889-4e6e-9a2e-cd606c759c53112856f5-42eb-463d-9629-299fdbd23bc15e7e9c84-56ee-4043-afa0-21fd2c142001Prevention0.001e3ed8979-5ba8-4f61-a5c7-f4b372ce4bc8112856f5-42eb-463d-9629-299fdbd23bc12f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.1abcd94a0-accb-419a-84d1-60e778f70ef1112856f5-42eb-463d-9629-299fdbd23bc1Changes in treatment concept not communicated2022-09-06T14:48:10.53314752022-09-06T14:48:10.533147628800truetruefalse00002e733bf2-a2b3-4764-892a-eca718e0ded4a3eb77c6-0cc1-4c75-8a64-10157b81ded8Corrupted Data transfer48545c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53110652023-02-28T09:46:04.39038880019dfaa-d7b7-47b8-8fcc-688d1fa670732e733bf2-a2b3-4764-892a-eca718e0ded4c5197300-5850-44d3-bfdf-1021f73c3ad4Prevention0.00118abdc6c-24e3-494c-ba98-06fe3c5bac602e733bf2-a2b3-4764-892a-eca718e0ded4f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.1cd8f70dc-fb3a-4a76-bdca-f69f460671462e733bf2-a2b3-4764-892a-eca718e0ded4a7c56c23-e776-4749-a044-8dba4a717804Barrier0.1d6427c51-14f2-41e4-a6e2-dcffe46ff9c32e733bf2-a2b3-4764-892a-eca718e0ded43b897e84-56bb-46c2-ab85-d80686e16168Barrier0.02e4aa5485-3b5c-4fd4-9439-b58e4ef00d8e2e733bf2-a2b3-4764-892a-eca718e0ded4Equipment malfunctioning; network issues; wrong system settings2022-09-06T14:48:10.53110742022-09-06T14:48:10.531107516000truetruefalse0000a76b0c4c-280c-4548-aede-ae471d62761928f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bCreate Planning Directives10012Added after Wegener et al.2023-01-26T13:30:33.04537842023-01-26T13:30:33.04537852d8c2a4b-de80-4227-9d7d-546e4af78184a76b0c4c-280c-4548-aede-ae471d627619Prescription in the Adaptive TPS is inconsistent with OIS.5.5545.54ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-26T13:44:10.4155242023-01-26T13:44:10.41552412d3ff651-70cf-4254-b303-4de6b3040c0c2d8c2a4b-de80-4227-9d7d-546e4af781843eeda996-17b0-45cf-9146-4f6a0e28bc8aPrevention0.003500000000000000575ca620c-4c6b-44cd-9ba1-dc301d214f4c2d8c2a4b-de80-4227-9d7d-546e4af78184f9c68445-5b7a-4898-9206-7b48f8cf145cBarrier0.013ddd517b-3fe1-44f4-8bf8-903b0711e32c2d8c2a4b-de80-4227-9d7d-546e4af78184Late change of prescription in OIS does not invalidate the plan.2023-01-26T13:44:10.42133822023-01-26T13:44:10.4213383d89275f7-b552-48f4-b4ac-201a516294942d8c2a4b-de80-4227-9d7d-546e4af78184Adaptive-specific failure mode2023-02-28T10:03:19.5191362023-02-28T10:03:19.519154111000falsefalsefalse00028db06482-dab0-44ca-a6ef-edb570159d93a76b0c4c-280c-4548-aede-ae471d627619Information for the treatment is not transferred between different professions6.14.84.86.14.8ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-26T10:40:59.57602812023-01-26T13:31:34.61371354b787749-5307-4345-8936-7bff6b3f1e128db06482-dab0-44ca-a6ef-edb570159d9357fd5fa3-4082-4a35-8961-5036c02a3596Barrier0.01857d7023e-59b6-48a7-a57e-48e391a650bb8db06482-dab0-44ca-a6ef-edb570159d9338e11cf4-8c93-41ee-8581-bdb2eaab86b9Prevention0.0054999999999999989ff620ca-3a86-48a5-aee7-a540e82a76df8db06482-dab0-44ca-a6ef-edb570159d93Poor Software Ergonomics;Suboptimal procedures;Lack of training2023-01-26T10:40:59.5840782023-01-26T10:40:59.5840781a2ae18fa-9987-4e55-9a26-c5c05586deed8db06482-dab0-44ca-a6ef-edb570159d93Added to EBRT to cover adaptive case2023-01-26T10:41:19.13408892023-02-28T09:54:55.5626224140.5400falsefalsefalse0001b3f5ec5f-4f22-4b80-be02-d9b242d80b9528f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bDose distribution optimization100160001-01-01T00:00:000001-01-01T00:00:003441cc64-a0aa-4013-9448-10c4ef2a4c2bb3f5ec5f-4f22-4b80-be02-d9b242d80b95Optimization failed8110810142dab32-eb08-407d-9b45-69cd5b5d70562022-09-06T14:48:10.5297492022-09-12T15:18:57.4552203cb844bcc-3c32-43a0-8125-7124068460293441cc64-a0aa-4013-9448-10c4ef2a4c2b2ded4b13-bdca-4f1b-95a3-c6bbc81342a5Prevention0.02f87f0084-dcbc-46df-a88f-de74f5b8d7593441cc64-a0aa-4013-9448-10c4ef2a4c2b365c3ec3-d94d-4091-b44d-fc2e42dac76aBarrier191841528-b1a4-48a5-aed9-69ab16b16d1a3441cc64-a0aa-4013-9448-10c4ef2a4c2b>Plan too complicated (bounded reality) >Physician intent not practicable (e.g. due to LINAC limitations or patient conditions)2022-09-06T14:48:10.52974982022-09-06T14:48:10.52974998000falsefalsefalse0000fa59215e-b98c-4d9f-8da8-0b6db44ec9f4b3f5ec5f-4f22-4b80-be02-d9b242d80b95Suboptimal plan produced888.1788.17c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.52839472023-01-26T13:51:35.1248786410ff776-9518-4f1e-842a-1d19e4b7523ffa59215e-b98c-4d9f-8da8-0b6db44ec9f4558906d9-0e25-4452-ad54-3b5790e70537Barrier0.25194475f07-790b-440f-a8ef-ed9ea838f65afa59215e-b98c-4d9f-8da8-0b6db44ec9f42f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.4a672e373-16d5-4e5e-9449-3f3f202eb0dffa59215e-b98c-4d9f-8da8-0b6db44ec9f46d80bffa-3e34-469e-8669-ba14eaa67cd3Prevention0.02e45e12b1-d79b-4109-a78f-7e8ad6eb499cfa59215e-b98c-4d9f-8da8-0b6db44ec9f4ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.1e8f65ec1-3ee5-4f11-8fb7-23593ebcc350fa59215e-b98c-4d9f-8da8-0b6db44ec9f4301bef85-d384-4b80-8345-a3392c426cffBarrier0.058e7371c7-8965-4335-9265-cc2a92c24495fa59215e-b98c-4d9f-8da8-0b6db44ec9f4Template not available; Lack of training or skills; inexperience; Failure to develop an effective plan due to; information not seen or sought; inappropriate assumptions; Information misinterpreted; Side effects not adequately considered; Mistaken options2022-09-06T14:48:10.52839552022-09-06T14:48:10.5283957522.8800truetruefalse0000cf5b8d5a-28cb-4b02-a3a8-28169de2801828f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfTransfer of images to treatment planning system1001.360001-01-01T00:00:002022-10-10T10:57:08.43563781c41a639-9972-4dc0-9bfd-3e3555a14fbdcf5b8d5a-28cb-4b02-a3a8-28169de28018Corrupt data transfer48646c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.51832642022-10-12T15:06:40.0710499474607b0-b24a-4398-9b78-f83e354259981c41a639-9972-4dc0-9bfd-3e3555a14fbdc95e1294-d690-40a5-a28e-458fdf38c697Prevention0.001fc59a3a5-6193-434b-9288-ab7c752c347a1c41a639-9972-4dc0-9bfd-3e3555a14fbdba1e4ba1-a21f-4d87-8093-881906287918Barrier0.05106e402a-6f27-47b0-bb65-26a7683b3f3a1c41a639-9972-4dc0-9bfd-3e3555a14fbd>Networking issues; >System settings2022-09-06T14:48:10.51832722022-09-06T14:48:10.518327419200falsefalsefalse0000cf746f88-b45a-4f2a-b3f0-f5530e23db9b28f78144-f82f-47e3-92ad-2c3ec0cebffaTreatment planning100132022-09-06T14:48:10.52161262022-09-06T14:48:10.52161272-1001e25e4aa1-e12c-41e9-9033-21beb75e7f7828f78144-f82f-47e3-92ad-2c3ec0cebffa59b65725-cedd-4dc5-a25f-e80c350ab6cfDocumentation of patient positioning and immobilization and ancillary devices1001.370001-01-01T00:00:000001-01-01T00:00:00801546ae-f984-4053-adfb-affdd0ab4760e25e4aa1-e12c-41e9-9033-21beb75e7f78Wrong documentation of positioning/immobilization directives68868c8d53bbb-7ad1-4d96-8be5-6eecc54ae6812022-09-06T14:48:10.53246442022-10-12T15:06:48.22106423c97bed2-312b-454e-86d2-c8dffe771e69801546ae-f984-4053-adfb-affdd0ab476077935f27-4b5e-47a3-9f66-f3352fa0ad30Prevention0.005a151fe74-32bf-4da5-8086-121aac2ab5e5801546ae-f984-4053-adfb-affdd0ab47606251ec96-7459-4d7e-97a5-030a5bc8bba9Barrier0.2be4a5cf2-dddd-4d62-aab2-f71714f6fbd7801546ae-f984-4053-adfb-affdd0ab4760f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.1d2453ad4-2abf-437a-93b0-1a8e77125fc6801546ae-f984-4053-adfb-affdd0ab476057abbcf0-715a-473b-948a-248e6dd78ab5Prevention0.03e5921285-8466-4ed0-9890-8f17c799a2cd801546ae-f984-4053-adfb-affdd0ab47602f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.1a330c170-b1c2-4581-966d-71c29e7d6fd0801546ae-f984-4053-adfb-affdd0ab4760>Failure to detect a developing problem: i. Environmental masking ii. Distraction iii. Loss of attention iv. Lack of information >Communication 2022-09-06T14:48:10.53246522022-09-06T14:48:10.532465438400truetruetrue0000e54c2701-5a1e-4b87-a9f2-33ac60e97c5a28f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Record of treatment delivery1002070001-01-01T00:00:000001-01-01T00:00:00676e67e3-a143-4372-a5d3-9522a1046ceee54c2701-5a1e-4b87-a9f2-33ac60e97c5aTreatment not recorded2992948488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.53851452022-10-12T15:17:30.150372315340893-e904-4f61-92e1-d4a713bd0765676e67e3-a143-4372-a5d3-9522a1046ceea0220572-8847-4080-8f2a-842f4a9c071ePrevention0.0002342b1d9c-9626-44cb-abf4-c723265ed87f676e67e3-a143-4372-a5d3-9522a1046ceef41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.1971529c1-2e0c-46f0-95ff-fdd2e66462fc676e67e3-a143-4372-a5d3-9522a1046cee90686915-b363-46bc-a90f-accb9adb25e8Barrier0.5f59de4e3-6258-496b-b338-52266840865e676e67e3-a143-4372-a5d3-9522a1046cee>Networking issues; >System settings, system failure; >Incomplete data transfer; >Distraction, loss of attention2022-09-06T14:48:10.5385162022-09-06T14:48:10.538516216200truetruefalse0000e81f1508-75ad-4d5e-aaf3-226577d4a15828f78144-f82f-47e3-92ad-2c3ec0cebffa3daedfac-fa43-47ab-980d-5902c532bf26Adaption100150001-01-01T00:00:002023-01-19T09:55:08.766591218d857b7-3bc3-453f-8e1c-1a4d5070b5c4e81f1508-75ad-4d5e-aaf3-226577d4a158Wrong Adaption because of large anatomic changes5.863.25.83.2ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-12T11:12:28.22438632023-01-19T10:08:25.43011374c8fffd-f0b3-412a-b303-bd1b705c2e6018d857b7-3bc3-453f-8e1c-1a4d5070b5c44828e70a-cc86-456b-927f-79fe4c191d68Prevention0.004399999999999999ca8526ae-8592-41d6-a408-2d24a9468ac818d857b7-3bc3-453f-8e1c-1a4d5070b5c44461a8ab-c6db-4ec9-b679-7d9b494c845eBarrier0.006d3174d0e-87cb-4046-bf43-fe06fb62b34118d857b7-3bc3-453f-8e1c-1a4d5070b5c4High Density Difference accompanied by large anatomic changes2023-01-12T11:12:28.23084652023-01-12T11:12:28.23084818570081b-e5b5-416e-9694-3d5e606407b618d857b7-3bc3-453f-8e1c-1a4d5070b5c4ART specific failure mode2023-01-12T11:13:37.02220332023-02-28T10:41:39.027412111.3600falsefalsefalse00041ba04e8c-2219-4952-8eb1-b33f49a0be77e81f1508-75ad-4d5e-aaf3-226577d4a158OAR Structures not contoured correctly during adoption process54.24.854.8a97a55bf-bd1b-4026-b6e5-f6697d5c13882023-01-12T11:48:25.39952292023-01-19T10:37:33.14823113b7d2cc1-df1d-41d4-a935-0fc47d46c2fb1ba04e8c-2219-4952-8eb1-b33f49a0be778e924e18-bbc6-4969-ad04-e4aa51969cbfPrevention0.00270aa97a8-5a6f-45ed-b450-0eb8f98839161ba04e8c-2219-4952-8eb1-b33f49a0be77d7b37145-285d-40b9-b13e-eb49181831efBarrier0.018ce543ef1-77bb-47e9-8cc9-c28d47bd62a91ba04e8c-2219-4952-8eb1-b33f49a0be77Limited accuracy of adaption algorithm;poor image quality2023-01-12T11:48:25.40462882023-01-12T11:48:25.4046301689c9343-5087-4dbd-aa87-774e5fc3b1d31ba04e8c-2219-4952-8eb1-b33f49a0be77ART specific failure mode2023-01-12T11:48:37.13253642023-02-28T10:39:15.7386113100.800falsefalsefalse0003530e02b5-ac6c-4004-abb8-5c9ccb6a67d4e81f1508-75ad-4d5e-aaf3-226577d4a158Adapted Plan with poor target coverage is approved6.15.64.66.14.6ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-12T11:43:31.15683032023-02-28T10:34:19.77613614fbb253f-3826-46f7-9256-8eddbd3d485d530e02b5-ac6c-4004-abb8-5c9ccb6a67d497e941fe-132d-4232-905a-fee46fa5beaaPrevention0.0054999999999999987749db70-3a97-4261-b22e-bb0fdf7c028c530e02b5-ac6c-4004-abb8-5c9ccb6a67d473d62502-615d-4303-a3f6-b7229564787cBarrier0.015999999999999997a1e8b6e6-44af-457e-9242-8ef571c985c2530e02b5-ac6c-4004-abb8-5c9ccb6a67d403f1e3c2-7c71-4837-b65d-93708d57981fBarrier0.58f9fbf21-8ed4-46f7-a68a-35772638091b530e02b5-ac6c-4004-abb8-5c9ccb6a67d4Details about initial PTV contouring are not known to oncologist reviewing adaptation2023-01-12T11:43:31.16241422023-01-12T11:43:31.1624158e45ac65b-5e03-4cc7-807a-e0c2001b82a2530e02b5-ac6c-4004-abb8-5c9ccb6a67d4ART specific failure mode2023-01-12T11:43:41.89593142023-02-28T10:32:00.1253077157.1400truetruefalse0001bb0ebd52-a96c-4ef2-b6ba-fc457e0abea2e81f1508-75ad-4d5e-aaf3-226577d4a158PTV not contoured correctly during adaption process74474a97a55bf-bd1b-4026-b6e5-f6697d5c13882023-01-12T11:46:11.08214142023-02-28T10:37:48.514144423db219f-ce57-445f-9ebc-473354957785bb0ebd52-a96c-4ef2-b6ba-fc457e0abea21032f509-e119-4bd0-a1ac-c7b76d8facb3Prevention0.01338a32b3-4580-48e5-9108-9264882d99e1bb0ebd52-a96c-4ef2-b6ba-fc457e0abea2a117b74e-e819-4c90-98bf-266030b26a9dBarrier0.0173d167d2-a018-474e-bbb1-5660a7b45b28bb0ebd52-a96c-4ef2-b6ba-fc457e0abea2Wrong Adaption Algorithm,poor daily images2023-01-12T11:46:11.08765982023-01-12T11:46:11.087661613f274c9-5dfe-4a6a-8b21-85b9f4568724bb0ebd52-a96c-4ef2-b6ba-fc457e0abea2ART specific failure mode2023-01-12T11:46:21.69033892023-02-28T10:38:01.734024311200falsefalsefalse0002dfa94a9a-dea1-45e9-affa-ea2f5dc82cf8e81f1508-75ad-4d5e-aaf3-226577d4a158Wrong Adapted Plan Approved5.5535.53ae08569c-0fbd-41b3-a8e3-8889fee8fadf2023-01-12T09:44:04.18033952023-01-19T10:47:39.3108366544410b2-a495-4d78-81e6-75b191798cdddfa94a9a-dea1-45e9-affa-ea2f5dc82cf86c49b15e-c8c2-4fde-a7a9-c444394987deBarrier0.005ec3cc085-8980-4551-acb7-322b94283454dfa94a9a-dea1-45e9-affa-ea2f5dc82cf8074cb49c-c935-4c9f-97f4-6fc52e776da3Prevention0.0035000000000000005ee49c0ee-cbfd-4c6f-ac2c-a71ff8ba6534dfa94a9a-dea1-45e9-affa-ea2f5dc82cf8Mix up of adapted plans during independent dose verification2023-01-12T09:44:04.18635252023-01-12T09:44:04.186354e847179d-3e78-4d3e-831b-4a011d5dc13bdfa94a9a-dea1-45e9-affa-ea2f5dc82cf8ART specific failure mode2023-01-12T10:21:00.3341472023-02-28T11:15:57.700569282.500falsefalsefalse0005f0c4b2a8-0bfb-4c4c-8c0f-e61089388f8928f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bRegistration of image sets100110001-01-01T00:00:000001-01-01T00:00:00dfb6970c-1dbb-4590-9db7-342134c97641f0c4b2a8-0bfb-4c4c-8c0f-e61089388f89Mix-up of imaging studies (e.g. previous CT scan used)8998948488ccf-b4e8-4b41-a5af-79d8ecd70b592022-09-06T14:48:10.52322532022-10-12T15:09:57.543096606896ab8-8e1c-49fa-a94a-eb90ee4a7c00dfb6970c-1dbb-4590-9db7-342134c976412f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.446db2abe-bb98-4fee-98a0-b208a4b4a506dfb6970c-1dbb-4590-9db7-342134c976410c718f66-a737-49c6-b916-690ef1375060Prevention0.0551a28176-6c41-4a41-9415-3849b87377cbdfb6970c-1dbb-4590-9db7-342134c97641ecf5e0be-5bcd-4159-93f2-9c5eb7a69bbcBarrier0.5822ff43c-fdeb-412a-9ea2-7ae6383e0fb4dfb6970c-1dbb-4590-9db7-342134c97641301bef85-d384-4b80-8345-a3392c426cffBarrier0.1c2b43c1b-8677-455a-a689-bdc45b6a3183dfb6970c-1dbb-4590-9db7-342134c97641b84c3b66-660f-4f0e-a434-5262d412964cPrevention0.0260bbc5d7-fcd6-46a6-bb9a-0adce8cd3eb1dfb6970c-1dbb-4590-9db7-342134c97641>Poor judgement >Slip causing physical error2022-09-06T14:48:10.52324762022-09-06T14:48:10.52324864800truetruetrue0000e78cf9a7-0ce9-4a54-aab1-f815518126e9f0c4b2a8-0bfb-4c4c-8c0f-e61089388f89Poor registration/fusion of imaging data sets76979ae08569c-0fbd-41b3-a8e3-8889fee8fadf2022-09-06T14:48:10.52161962022-10-12T15:18:30.3408883082ad357-bf3c-4ded-a74a-3238471fe492e78cf9a7-0ce9-4a54-aab1-f815518126e9329a79b0-9bc1-4c95-8fc0-5e02ca70f2dbPrevention0.052568218f-8466-4dcf-b6fc-1c3deb0a302de78cf9a7-0ce9-4a54-aab1-f815518126e92a336869-ff40-4ffc-816f-49b831f51e93Prevention0.018676c88a-3eed-4382-bc7f-afa423001cc6e78cf9a7-0ce9-4a54-aab1-f815518126e9ea8ba5ef-1c63-4ee6-af76-9d38493d2199Barrier0.1a3d99285-083c-47f0-917f-14318173e4b7e78cf9a7-0ce9-4a54-aab1-f815518126e9a08dbe40-dae9-47bf-a447-ee2adebd41a4Barrier0.5c14738a8-f83f-4cbc-82f1-ad299ecc7320e78cf9a7-0ce9-4a54-aab1-f815518126e937d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.1f91b8aaf-009a-4d71-9cd6-7f99f83f5568e78cf9a7-0ce9-4a54-aab1-f815518126e96f6fe77a-c80c-46ce-9d31-df65ab4855b1Prevention0.0263124452-11d5-43b5-b552-066347f72cbee78cf9a7-0ce9-4a54-aab1-f815518126e9>Geometric distoritions, >Poor spatial resolution, >Anatomical deviations or changes between studies2022-09-06T14:48:10.52162082022-09-06T14:48:10.521620937800truetruetrue0000ffe750c9-0918-4ad5-b56a-cd3e27e7a4e128f78144-f82f-47e3-92ad-2c3ec0cebffacf746f88-b45a-4f2a-b3f0-f5530e23db9bSpecial precautions for pacemakers2150001-01-01T00:00:000001-01-01T00:00:00d3eede8c-1317-4740-9a9a-70ef31e3a1c0ffe750c9-0918-4ad5-b56a-cd3e27e7a4e1Neglect of pacemaker61096971ae1273-b59d-45da-a1a7-573718fbe6c62022-09-06T14:48:10.52693812022-10-12T15:04:00.944494644c9c74f-3f61-4772-97b0-3bef04376284d3eede8c-1317-4740-9a9a-70ef31e3a1c0f41c23a4-77f5-4c3f-b913-572ad606e594Barrier0.16598a00a-5f25-41a0-a14c-ff37c5c03c39d3eede8c-1317-4740-9a9a-70ef31e3a1c0301bef85-d384-4b80-8345-a3392c426cffBarrier0.0586475294-0ab3-425f-8856-aae1e459e7b2d3eede8c-1317-4740-9a9a-70ef31e3a1c037d9a27e-4c76-476d-aa25-dd1dfc462d2cBarrier0.193b8484f-1f1d-4fe4-bbe2-70ef36fadb8ed3eede8c-1317-4740-9a9a-70ef31e3a1c083f93c51-cfda-4125-a983-a1121a43fe57Prevention0.005c9c54932-c3bd-475a-867c-10d0000bc266d3eede8c-1317-4740-9a9a-70ef31e3a1c02f4fa8ed-aee1-45c0-80c4-d177e9f6e2beBarrier0.4f3532bf4-4ed5-4538-a062-53605291f988d3eede8c-1317-4740-9a9a-70ef31e3a1c0c6a23aba-7588-494f-ab14-7aea27594905Barrier0.5295088fd-e4d2-4632-91cc-0c17a9f52bc8d3eede8c-1317-4740-9a9a-70ef31e3a1c0Poor 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