ABSTRACT
Patient safety and quality of care is integral to the practice of health care, but is of special concern in radiation oncology due to the complexity of the processes, the many hand-offs between various professionals, the protracted timeline for the preparation and execution of treatment, and the many technical components from multiple vendors. In a complex environment like health care, error prevention efforts can have unintended consequences. A classic example of this is the experience with clinical provider order entry (CPOE) systems. One important motivation for implementing CPOE systems is to reduce error, that is, reduce adverse drug events related to medication error by eliminating transcription errors and other faults. Beam's eye view (BEV) imaging can serve as an important component of a patient safety and quality management program. This is demonstrated in a handful of studies both in operational practice and also from a more theoretical assessment of detectability.
