Physics Contribution Quality Assurance With Plan Veto: Reincarnation of a Record and Verify System and Its Potential Value Camille E. Noel, PhD,* VeeraRajesh Gutti, PhD, y Walter Bosch, DSc,* Sasa Mutic, PhD,* Eric Ford, PhD, z Stephanie Terezakis, MD, x and Lakshmi Santanam, PhD* *Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri; y Department of Radiation Oncology, Scott and White Healthcare, Temple, Texas; z Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington; and x Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland Received Oct 23, 2013, and in revised form Dec 23, 2013. Accepted for publication Dec 27, 2013. Summary In an attempt to investigate potential safety flaws related to the complexity of emerging technologies in ra- diation therapy and to the associated processes, we identify the essential ele- ments of the Quality Assur- ance with Plan Veto (QAPV) checker using Failure Modes and Effects Analysis (FMEA) and Incident Learning System (ILS). High-risk errors asso- ciated with corrupted Digital Imaging and Communica- tions in Medicine (DICOM) plan parameters could be reduced with the use of QAPV, and a safe and effi- cient treatment transfer be- tween multiple systems along with an effective treatment delivery is achievable. Purpose: To quantify the potential impact of the Integrating the Healthcare EnterpriseeRadia- tion Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. Methods and Materials: An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter incon- sistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine). Critical Digital Imaging and Communications in Medi- cine RT plan parameters were identified. Each event was scored for importance using the Failure Mode and Effects Analysis methodology. Potential error occurrence (frequency) was derived ac- cording to the collected event data, along with the potential event severity, and the probability of detection with and without the theoretical implementation of the QAPV plan comparison check. Failure Mode and Effects Analysis Risk Priority Numbers (RPNs) with and without QAPV were compared to quantify the potential benefit of clinical implementation of QAPV. Results: The implementation of QAPV could reduce the RPN values for 15 of 22 (71%) of eval- uated parameters, with an overall average reduction in RPN of 68 (range, 0-216). For the 6 high- risk parameters (>200), the average reduction in RPN value was 163 (range, 108-216). The RPN value reduction for the intermediate-risk (200 > RPN > 100) parameters was (0-140). With QAPV, the largest RPN value for “Beam Meterset” was reduced from 324 to 108. The maximum reduction in RPN value was for Beam Meterset (216, 66.7%), whereas the maximum percentage reduction was for Cumulative Meterset Weight (80, 88.9%). Conclusion: This analysis quantifies the value of the Integrating the Healthcare EnterpriseeRa- diation Oncology QAPV implementation in clinical workflow. We demonstrate that although QAPV does not provide a comprehensive solution for error prevention in RT, it can have a sig- nificant impact on a subset of the most severe clinically observed events. Ó 2014 Elsevier Inc. Reprint requests to: Lakshmi Santanam, PhD, Washington University School of Medicine, Department of Radiation Oncology, Campus Box 8224, 4921 Parkview Place, St. Louis, MO 63110-1093. Tel: (314) 747- 3721; E-mail: lsantanam@radonc.wustl.edu Partial funding for this work was provided by Varian Medical Systems. Conflict of interest: none. Int J Radiation Oncol Biol Phys, Vol. 88, No. 5, pp. 1161e1166, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.12.044 Radiation Oncology International Journal of biology physics www.redjournal.org