Cartographie et gestion des risques en radiothérapie : un travail commun du département de radiothérapie et du département de la qualité et de la gestion des risques de l’institut Jean-Godinot

Implementation of the global risk analysis in pulsed-dose rate brachytherapy: methods and results

PURPOSE

To report the application of the global risk analysis (GRA) in the pulsed-dose rate (PDR) brachytherapy workflow.

MATERIAL AND METHODS

Analyses were led by a multidisciplinary working group established within the unit with the guidance of a quality engineer. First, a mapping of hazardous situations was developed as a result of interactions between the patient workflow for a treatment using PDR brachytherapy split into 51 sub-phases with a comprehensive list of the hazards that he/she faces (44). Interactions, when relevant, were sorted by level of priority: to be treated immediately, secondarily (the group is not entitled to treat the situation), or later (safe situation). Secondly, for each high priority dangerous situation, scenarios were developed to anticipate their potential consequences. Criticality was assessed, using likelihood and severity scales and a matrix, which allocated risks into categories: acceptable (C1), tolerable under control (C2) and unacceptable (C3). Then, corrective actions were proposed and planned when relevant, after assessment of their feasibility with a scale of effort. Finally, the criticality of the scenarios was reevaluated, taking into account the implementation of these actions, leading to a residual risk mapping, which could trigger additional proposals of actions.

RESULTS

Two thousand one hundred and eighty-four potential interactions between the list of hazards and the workflow were analyzed. Mapping of dangerous situations identified 213 relevant interactions, from which 61 were considered with high priority. One hundred and twenty-six scenarios were generated: 68 with a low criticality (74.3%), 58 with an intermediate score (25.7%). No scenario with the highest criticality was individualized. Twenty-one corrective actions were planned. Mapping of residual risk resulted in the disappearance of most C2 risks, leaving 5 C2 scenarios (4%), for which four monitoring indicators were implemented in addition to the corrected actions decided on.

CONCLUSION

The implementation of the GRA appeared feasible, and led to implement 21 corrective actions, based on scenarios and not on incidents.

[Risk analysis in radiation therapy: state of the art]

Five radiotherapy accidents, from which two serial, occurred in France from 2003 to 2007, led the authorities to establish a roadmap for securing radiotherapy. By analogy with industrial processes, a technical decision form the French Nuclear Safety Authority in 2008 requires radiotherapy professionals to conduct analyzes of risks to patients. The process of risk analysis had been tested in three pilot centers, before the occurrence of accidents, with the creation of cells feedback. The regulation now requires all radiotherapy services to have similar structures to collect precursor events, incidents and accidents, to perform analyzes following rigorous methods and to initiate corrective actions. At the same time, it is also required to conduct analyzes a priori, less intuitive, and usually require the help of a quality engineer, with the aim of reducing risk. The progressive implementation of these devices is part of an overall policy to improve the quality of radiotherapy. Since 2007, no radiotherapy accident was reported.

[Functional modeling for risk analysis in radiotherapy]

PURPOSE

This document presents a systematic and structured approach for functional modeling for risk analysis in radiotherapy, aiming to reconcile the need, on one hand, for a method that can be applied generally and, on the other hand, for a method that provides a highly precise model.

MATERIALS AND METHODS

The approach relies on new functional structuring patterns and flux analysis, derived from system engineering and knowledge engineering.

RESULTS

The method affords strong support for the development of detailed models of the patient's process through a department of radiotherapy. Lack of structure of the actual process in a particular department may be easily identified leading to the development of specific procedures for the improvement of security.

CONCLUSION

Modeling approach derived from engineering may be used for functional modeling for risk analysis in radiotherapy.

[FMEA applied to the radiotherapy patient care process]

PURPOSE

Failure modes and effects analysis (FMEA), is a risk analysis method used at the Radiotherapy Department of Institute Sainte-Catherine as part of a strategy seeking to continuously improve the quality and security of treatments.

PATIENTS AND METHODS

The method comprises several steps: definition of main processes; for each of them, description for every step of prescription, treatment preparation, treatment application; identification of the possible risks, their consequences, their origins; research of existing safety elements which may avoid these risks; grading of risks to assign a criticality score resulting in a numerical organisation of the risks. Finally, the impact of proposed corrective actions was then estimated by a new grading round.

RESULTS

For each process studied, a detailed map of the risks was obtained, facilitating the identification of priority actions to be undertaken. For example, we obtain five steps in patient treatment planning with an unacceptable level of risk, 62 a level of moderate risk and 31 an acceptable level of risk.

CONCLUSION

The FMEA method, used in the industrial domain and applied here to health care, is an effective tool for the management of risks in patient care. However, the time and training requirements necessary to implement this method should not be underestimated.