[Efforts toward Patient Safety: Development of System and Education of Non-Technical Skill]

Advanced radiotherapy such as intensity-modulated radiotherapy offers many advantages of high accuracy and efficiency of radiotherapy. To date, many technical guidelines with description of quality assurance and quality control have been reported. However, some reports indicated that human factor and environment is major cause of radiotherapy incidents. If radiotherapy systems depend on automation and computer system, individual risk management is degraded and ability of preventing radiotherapy incidents weaken. Recently, the American Association of Physicists in Medicine (AAPM) task group-100 was reported and it has a new concept guideline, which proposed the comprehensive risk management and education of non-technical skills for overall radiotherapy processes. The TG-100 recommends implementation of process map, reporting system, risk assessment such as failure mode and effects analysis (FMEA) and fault tree analysis (FTA) especially for advanced radiotherapy. In this paper, we described effective and efficient procedures to improve the treatment processes and education of non-technical skills using the such management tools proposed by the TG-100 guide-lines.