| Sumario: | Integrated Magnetic Resonance Imaging Linear Accelerators (MRL) allow for daily on-line adaptive treatment to account for anatomical changes, however, this introduces complexities into the workflow. Incident analysis after a significant safety event at our institution revealed the need for enhanced communication, decision-making, and structured mechanisms to address clinical uncertainties in this high-stakes environment. We introduced two novel tools, MRL Connect and Escalation of Concern, to strengthen situational awareness and patient care in adaptive radiotherapy. MRL Connect was conceived as a pre-treatment multidisciplinary debrief to address the challenges mentioned above. It is a guided discussion framework that involves structured discussions among radiation oncologists, radiation therapists, and medical physicists to address key complexities such as anatomical changes, image quality, and adherence to protocols. The framework encourages participation of individuals with diverse expertise to ensure comprehensive decision-making. MRL connect was piloted with initial focus on pancreas and brain cases. Feedback was collected using qualitative methods and surveys, and the process underwent iterative refinement through Plan-Do-Study-Act (PDSA) cycles. These iterations incorporated feedback on workflow efficiency, clarity of roles, and interdisciplinary engagement, making the process more robust and aligned with clinical needs. Escalation of Concern was introduced to provide a structured mechanism for addressing safety concerns, communication breakdowns, and loss of situational awareness during adaptive treatments. It is a protocol which includes a defined criteria for initiating escalations and training on the 'Two-Step Challenge Method', a systematic approach where a team member first raises a concern (Step 1), ensuring that it is explicitly acknowledged; if the concern is not addressed satisfactorily, the team member escalates by restating the concern with increased urgency and clarity (Step 2). This method helps maintain focus and psychological safety in critical discussions. MRL Connect is designed to enhance interdisciplinary communication and rapid decision-making critical to adaptive radiotherapy, which relies on daily treatment personalization. It provides a structured platform for identifying and addressing potential workflow and clinical challenges. The Escalation of Concern framework promotes psychological safety, enabling team members to voice concerns without fear of reprisal. It strengthens team cohesion and proactive risk management. Challenges include integrating these processes into the existing workflow while maintaining efficiency, as well as addressing variability in engagement levels across disciplines. The initial pilot of MRL Connect demonstrated notable improvements in team communication, workflow clarity, and situational awareness during adaptive radiotherapy. Early feedback highlighted enhanced decision-making processes and greater alignment across disciplines, ultimately contributing to improved patient safety and treatment precision. Once the escalation of concern framework is embedded into the MRL workflow, patient safety will be enhanced further, team dynamics improved, and a Just Culture promoted within the MRL. Future evaluations will focus the impact of these initiatives on staff engagement, risk mitigation, and overall patient care quality, furthering the broader goals of adaptive radiotherapy.
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