Purpose: The pretreatment physics plan review is a standard tool for ensuring treatment quality. Studies have shown that the majority of errors in radiation oncology originate in treatment planning, which underscores the importance of the pretreatment physics plan review. This quality assurance measure is fundamentally important and central to the safety of patients and the quality of care that they receive. However, little is known about its effectiveness. The purpose of this study was to analyze reported incidents to quantify the effectiveness of the pretreatment physics plan review with the goal of improving it. Methods: This study analyzed 522 potentially severe or critical near-miss events within an institutional incident learning system collected over a three-year period. Of these 522 events, 356 originated at a workflow point that was prior to the pretreatment physics plan review. The remaining 166 events originated after the pretreatment physics plan review and were not considered in the study. The applicable 356 events were classified into one of the three categories: (1) events detected by the pretreatment physics plan review, (2) events not detected but "potentially detectable" by the physics review, and (3) events "not detectable" by the physics review. Potentially detectable events were further classified by which specific checks performed during the pretreatment physics plan review detected or could have detected the event. For these events, the associated specific check was also evaluated as to the possibility of automating that check given current data structures. For comparison, a similar analysis was carried out on 81 events from the international SAFRON radiation oncology incident learning system. Results: Of the 356 applicable events from the institutional database, 180/356 (51%) were detected or could have been detected by the pretreatment physics plan review. Of these events, 125 actually passed through the physics review; however, only 38% (47/125) were actually detected at the review. Of the 81 events from the SAFRON database, 66/81 (81%) were potentially detectable by the pretreatment physics plan review. From the institutional database, three specific physics checks were particularly effective at detecting events (combined effectiveness of 38%): verifying the isocenter (39/180), verifying DRRs (17/180), and verifying that the plan matched the prescription (12/180). The most effective checks from the SAFRON database were verifying that the plan matched the prescription (13/66) and verifying the field parameters in the record and verify system against those in the plan (23/66). Software-based plan checking systems, if available, would have potential effectiveness of 29% and 64% at detecting events from the institutional and SAFRON databases, respectively. Conclusions: Pretreatment physics plan review is a key safety measure and can detect a high percentage of errors. However, the majority of errors that potentially could have been detected were not detected in this study, indicating the need to improve the pretreatment physics plan review performance. Suggestions for improvement include the automation of specific physics checks performed during the pretreatment physics plan review and the standardization of the review process. (C) 2016 American Association of Physicists in Medicine.