Aim: A state diagram can be used to map systems and understand processes. Mapping objects (people, tools) and transitions between discrete states increases understanding of the pathways to reach a successful terminal state or a failed state (error or incident). A state diagram was used as part of a case study to investigate an incident where treatment was delivered while radiation treatment was being re-considered. The goal was to explore the ability of this tool to identify radiation therapy practice changes that may reduce or eliminate the potential for treatment to proceed when not intended, or the actions required to hold treatment once a treatment course has commenced. Process: The incident being investigated was a case where all steps were completed for treatment to proceed (treatment plan and prescription were approved), however due to patient co-morbidities and hospital admission, the decision of whether to proceed with treatment was still under consideration when the first fraction of treatment was delivered. To map out the transitions surrounding this event, a state diagram was created. 4 objects and substates were identified: Intention to treat (yes, no, undecided), Patient location (present, absent), Prescription status (none, unapproved, approved) and Plan status (none, unapproved, approved, rejected, discontinued). A composite state diagram was then used to map out the 90 possible combinations of substates including a successful terminal state (intended treatment delivery), and failed states (unintended treatment delivery). Benefits/Challenges: Mapping a system using a state diagram directs attention towards key activities that are required for an error to occur. The goal is to direct process improvement to prevent not only the failed state, but to keep the state of the system more than one step away from the failed state and create barriers or detection mechanisms at these transitions. This tool indicated that some treatment plan status changes require significant rework; treatment prescription changes are low effort but highly dependent on an individual; and that ‘on hold’ status of the plan and prescription is required to make the intention unambiguous. The complexity of a state diagram increases with the number of objects, states, substates and transition pathways. It was necessary to exclude objects that are unreliable or out of programmatic control such as free-text documentation, in person communication, and patient transportation arrangements. Exclusion of these objects to prevent overcomplication was a limitation of the state diagram. Impact/Outcomes: In this case, the state diagram helped to identify 6 states that were one step away from a failed state. Clear identification of these states can be targeted for future process improvement. State diagrams were found to be a useful tool in analyzing the pathways that can lead to unintended radiation treatment delivery and to examine the processes and transitions leading to specific events in radiation therapy.