PurposeOnline adaptive radiotherapy (oART) treatment planning requires evaluating the temporal robustness of reference plans, anticipating the potential changes during treatment courses that may even lead to risks unique to the adaptive workflow. This study conducted a risk analysis of the CBCT-guided adaptive workflow and is the first to assess an adaptive specific reference planning review that mitigates risk in the planning process to prevent events and treatment deficiencies during adaptation. Methods and MaterialsA quality management team of medical physicists, residents, physicians, and radiation therapists performed a fault tree analysis, and failure mode and effects analysis (FMEA). Fault trees were created for under/overdosing targets, treatment deficiencies, as well as assisted in identifying failure modes for the FMEA. Treatment deficiency was defined to include a non-ideal oART plan resulting in treatment with a lower quality plan (either oART or scheduled plan), treatment delay, or cancelling treatment for the day. A reference planning checklist was created to catch failure modes before reaching the patient. Risk priority numbers (RPN=Severity*Detectability*Occurrence) were scored with and without the reference planning checklist to quantify risk mitigation. A root cause analysis was conducted for an event where an adaptive plan failed to generate. ResultsThe reference planning checklist (with items covering patient background, contouring/planning robustness for anatomy variability, and machine limitations) reduced the RPN for all failure modes. Only 1 failure mode with a risk priority number >150 occurred with the reference planning checklist compared to 29 failure modes without, including 14 adaptive specific failure modes. Contouring, planning, setup, scheduling, and documentation errors were identified during the fault tree analysis. 29/70 errors were adaptive specific. The reference planning checklist could address 23/33 for over/under dosing and 28/37 errors for treatment deficiency. The root cause analysis highlighted the need for checking setup prior to adaptive plan delivery, and time-out checklist. ConclusionsThe reference planning checklist improved detection of the failure modes and improves the quality and robustness of the plans produced for oART. It is ideally performed before physician plan review to prevent last minute re-plan (before or after first adaptive treatment) and delay of patient start. The checklist presented can be modified based on failures specific to individual clinics and utilized at various planning steps based on available resources.