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Kornek D, Lotter M, Szkitsak J, Dürrbeck C, Karius A, Ott OJ, Brandl C, Bert C. Improving the safety of radiotherapy treatment processes via incident-driven FMEA feedback loops. J Appl Clin Med Phys 2024:e14455. [PMID: 39101683 DOI: 10.1002/acm2.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/22/2024] [Accepted: 06/26/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Failure mode and effects analysis (FMEA) is a valuable tool for radiotherapy risk assessment, yet its outputs might be unreliable due to failures not being identified or due to a lack of accurate error rates. PURPOSE A novel incident reporting system (IRS) linked to an FMEA database was tested and evaluated. The study investigated whether the system was suitable for validating a previously performed analysis and whether it could provide accurate error rates to support the expert occurrence ratings of previously identified failure modes. METHODS Twenty-three pre-identified failure modes of our external beam radiotherapy process, covering the process steps from patient admission to treatment delivery, were proffered on dedicated FMEA feedback and incident reporting terminals generated by the IRS. The clinical setting involved a computed tomography scanner, dosimetry, and five linacs. Incoming reports were used as basis to identify additional failure modes or confirm initial ones. The Kruskal-Wallis H test was applied to compare the risk priorities of the retrospective and prospective failure modes. Wald's sequential probability ratio test was used to investigate the correctness of the experts' occurrence ratings by means of the number of incoming reports. RESULTS Over a 15-month period, 304 reports were submitted. There were 0.005 (confidence interval [CI], 0.0014-0.0082) reported incidents per imaging study and 0.0006 (CI, 0.0003-0.0009) reported incidents per treatment fraction. Sixteen additional failure modes could be identified, and their risk priorities did not differ from those of the initial failure modes (p = 0.954). One failure mode occurrence rating could be increased, whereas the other 22 occurrence ratings could not be disproved. CONCLUSIONS Our approach is suitable for validating FMEAs and deducing additional failure modes on a continual basis. Accurate error rates can only be provided if a sufficient number of reports is available.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Juliane Szkitsak
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christopher Dürrbeck
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Carolin Brandl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Kornek D, Menichelli D, Leske J, Hofmann M, Antkiewicz D, Brandt T, Ott OJ, Lotter M, Lang-Welzenbach M, Fietkau R, Bert C. Development and clinical implementation of a digital system for risk assessments for radiation therapy. Z Med Phys 2024; 34:371-383. [PMID: 37666699 PMCID: PMC11384085 DOI: 10.1016/j.zemedi.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023]
Abstract
Before introducing new treatment techniques, an investigation of hazards due to unintentional radiation exposures is a reasonable activity for proactively increasing patient safety. As dedicated software is scarce, we developed a tool for risk assessment to design a quality management program based on best practice methods, i.e., process mapping, failure modes and effects analysis and fault tree analysis. Implemented as a web database application, a single dataset was used to describe the treatment process and its failure modes. The design of the system and dataset allowed failure modes to be represented both visually as fault trees and in a tabular form. Following the commissioning of the software for our department, previously conducted risk assessments were migrated to the new system after being fully re-assessed which revealed a shift in risk priorities. Furthermore, a weighting factor was investigated to bring risk levels of the migrated assessments into perspective. The compensation did not affect high priorities but did re-prioritize in the midrange of the ranking. We conclude that the tool is suitable to conduct multiple risk assessments and concomitantly keep track of the overall quality management activities.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | | | - Jörg Leske
- IBA Dosimetry GmbH, 90592 Schwarzenbruck, Germany.
| | | | | | - Tobias Brandt
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Marga Lang-Welzenbach
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
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Kornek D, Bert C. Process failure mode and effects analysis for external beam radiotherapy: Introducing a literature-based template and a novel action priority. Z Med Phys 2024; 34:358-370. [PMID: 38429170 PMCID: PMC11384953 DOI: 10.1016/j.zemedi.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/21/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The first aim of the study was to create a general template for analyzing potential failures in external beam radiotherapy, EBRT, using the process failure mode and effects analysis (PFMEA). The second aim was to modify the action priority (AP), a novel prioritization method originally introduced by the Automotive Industry Action Group (AIAG), to work with different severity, occurrence, and detection rating systems used in radiation oncology. METHODS AND MATERIALS The AIAG PFMEA approach was employed in combination with an extensive literature survey to develop the EBRT-PFMEA template. Subsets of high-risk failure modes found through the literature survey were added to the template where applicable. Our modified AP for radiation oncology (RO AP) was defined using a weighted sum of severity, occurrence, and detectability. Then, Monte Carlo simulations were conducted to compare the original AIAG AP, the RO AP, and the risk priority number (RPN). The results of the simulations were used to determine the number of additional corrective actions per failure mode and to parametrize the RO AP to our department's rating system. RESULTS An EBRT-PFMEA template comprising 75 high-risk failure modes could be compiled. The AIAG AP required 1.7 additional corrective actions per failure mode, while the RO AP ranged from 1.3 to 3.5, and the RPN required 3.6. The RO AP could be parametrized so that it suited our rating system and evaluated severity, occurrence, and detection ratings equally to the AIAG AP. CONCLUSIONS An adjustable EBRT-PFMEA template is provided which can be used as a practical starting point for creating institution-specific templates. Moreover, the RO AP introduces transparent action levels that can be adapted to any rating system.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
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Takemori M, Nakamura S, Sofue T, Ito M, Goka T, Miura Y, Iijima K, Chiba T, Nakayama H, Nakaichi T, Mikasa S, Takano Y, Kon M, Shuto Y, Urago Y, Nishitani M, Kashihara T, Takahashi K, Murakami N, Nishio T, Okamoto H, Chang W, Igaki H. Failure modes and effects analysis study for accelerator-based Boron Neutron Capture Therapy. Med Phys 2023; 50:424-439. [PMID: 36412161 DOI: 10.1002/mp.16104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Boron Neutron Capture Therapy (BNCT) has recently been used in clinical oncology thanks to recent developments of accelerator-based BNCT systems. Although there are some specific processes for BNCT, they have not yet been discussed in detail. PURPOSE The aim of this study is to provide comprehensive data on the risk of accelerator-based BNCT system to institutions planning to implement an accelerator-based BNCT system. METHODS In this study, failure mode and effects analysis (FMEA) was performed based on a treatment process map prepared for the accelerator-based BNCT system. A multidisciplinary team consisting of a medical doctor (MD), a registered nurse (RN), two medical physicists (MP), and three radiologic technologists (RT) identified the failure modes (FMs). Occurrence (O), severity (S), and detectability (D) were scored on a scale of 10, respectively. For each failure mode (FM), risk priority number (RPN) was calculated by multiplying the values of O, S, and D, and it was then categorized as high risk, very high risk, and other. Additionally, FMs were statistically compared in terms of countermeasures, associated occupations, and whether or not they were the patient-derived. RESULTS The identified FMs for BNCT were 165 in which 30 and 17 FMs were classified as high risk and very high risk, respectively. Additionally, 71 FMs were accelerator-based BNCT-specific FMs in which 18 and 5 FMs were classified as high risk and very high risk, respectively. The FMs for which countermeasures were "Education" or "Confirmation" were statistically significantly higher for S than the others (p = 0.019). As the number of BNCT facilities is expected to increase, staff education is even more important. Comparing patient-derived and other FMs, O tended to be higher in patient-derived FMs. This could be because the non-patient-derived FMs included events that could be controlled by software, whereas the patient-derived FMs were impossible to prevent and might also depend on the patient's condition. Alternatively, there were non-patient-derived FMs with higher D, which were difficult to detect mechanically and were classified as more than high risk. In O, significantly higher values (p = 0.096) were found for FMs from MD and RN associated with much patient intervention compared to FMs from MP and RT less patient intervention. Comparing conventional radiotherapy and accelerator-based BNCT, although there were events with comparable risk in same FMs, there were also events with different risk in same FMs. They could be related to differences in the physical characteristics of the two modalities. CONCLUSIONS This study is the first report for conducting a risk analysis for BNCT using FMEA. Thus, this study provides comprehensive data needed for quality assurance/quality control (QA/QC) in the treatment process for facilities considering the implementation of accelerator-based BNCT in the future. Because many BNCT-specific risks were discussed, it is important to understand the characteristics of BNCT and to take adequate measures in advance. If the effects of all FMs and countermeasures are discussed by multidisciplinary team, it will be possible to take countermeasures against individual FMs from many perspectives and provide BNCT more safely and effectively.
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Affiliation(s)
- Mihiro Takemori
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan.,Division of Boron Neutron Capture Therapy, National Cancer Center Exploratory Oncology Research & Clinical Trial Center, Chuo-ku, Tokyo, Japan
| | - Satoshi Nakamura
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Division of Boron Neutron Capture Therapy, National Cancer Center Exploratory Oncology Research & Clinical Trial Center, Chuo-ku, Tokyo, Japan.,Medical Physics Laboratory, Division of Health Science, Graduate School of Medicine, Osaka University, Suita city, Osaka, Japan
| | - Toshimitsu Sofue
- Department of Radiological Technology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Mikiko Ito
- Department of Nursing, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Tomonori Goka
- Department of Radiological Technology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yuki Miura
- Department of Radiological Technology, National Cancer Center Hospital East, Kashiwa-shi, Chiba, Japan
| | - Kotaro Iijima
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Takahito Chiba
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Hiroki Nakayama
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Tetsu Nakaichi
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Shohei Mikasa
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yuki Takano
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Mitsuhiro Kon
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Technology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yasunori Shuto
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Technology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yuka Urago
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Masato Nishitani
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Teiji Nishio
- Medical Physics Laboratory, Division of Health Science, Graduate School of Medicine, Osaka University, Suita city, Osaka, Japan
| | - Hiroyuki Okamoto
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Weishan Chang
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Hiroshi Igaki
- Division of Boron Neutron Capture Therapy, National Cancer Center Exploratory Oncology Research & Clinical Trial Center, Chuo-ku, Tokyo, Japan.,Department of Radiation Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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