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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 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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Nishioka S, Okamoto H, Chiba T, Kito S, Ishihara Y, Isono M, Ono T, Mizoguchi A, Mizuno N, Tohyama N, Kurooka M, Ota S, Shimizu D. Technical note: A universal worksheet for failure mode and effects analysis-A project of the Japanese College of Medical Physics. Med Phys 2024; 51:3658-3664. [PMID: 38507277 DOI: 10.1002/mp.17033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Failure mode and effects analysis (FMEA), which is an effective tool for error prevention, has garnered considerable attention in radiotherapy. FMEA can be performed individually, by a group or committee, and online. PURPOSE To meet the needs of FMEA for various purposes and improve its accessibility, we developed a simple, self-contained, and versatile web-based FMEA risk analysis worksheet. METHODS We developed an FMEA worksheet using Google products, such as Google Sheets, Google Forms, and Google Apps Script. The main sheet was created in Google Sheets and contained elements necessary for performing FMEA by a single person. Automated tasks were implemented using Apps Script to facilitate multiperson FMEA; these functions were built into buttons located on the main sheet. RESULTS The usability of the FMEA worksheet was tested in several situations. The worksheet was feasible for individual, multiperson, seminar, meeting, and online purposes. Simultaneous online editing, automated survey form creation, automatic analysis, and the ability to respond to the form from multiple devices, including mobile phones, were particularly useful for online and multiperson FMEA. Automation enabled through Google Apps Script reduced the FMEA workload. CONCLUSIONS The FMEA worksheet is versatile and has a seamless workflow that promotes collaborative work for safety.
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Affiliation(s)
- Shie Nishioka
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Kito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Yoshitomo Ishihara
- Department of Radiation Oncology, Division of Medical Physics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Masaru Isono
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomohiro Ono
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Asumi Mizoguchi
- Department of Radiology, Kurume University Hospital, Fukuoka, Japan
| | - Norifumi Mizuno
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Makuhari Clinic for Advanced Imaging, Cancer Screening, and High-Precision Radiotherapy, Chiba, Japan
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Seiichi Ota
- Department of Medical Technology, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Shimizu
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Ma M, Yan H, Li M, Tian Y, Zhang K, Men K, Dai J. Determining the quality control frequency of an MR-linac using risk matrix (RM) analysis. J Appl Clin Med Phys 2023:e13984. [PMID: 37095706 PMCID: PMC10402679 DOI: 10.1002/acm2.13984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
PURPOSE Quality control (QC) is performed routinely through professional guidelines. However, the recommended QC frequency may not be optimal among different institutional settings. Here we propose a novel method for determining the optimal QC frequency using risk matrix (RM) analysis. METHODS AND MATERIALS A newly installed Magnetic Resonance linac (MR-linac) was chosen as the testing platform and six routine QC items were investigated. Failures of these QC items can adversely affect treatment outcome for the patient. Accordingly, each QC item with its assigned frequency forms a unique failure mode (FM). Using FM-effect analysis (FMEA), the severity (S), occurrence (O), and detection (D) of each FM was obtained. Next, S and D based on RM was used to determine the appropriate QC frequency. Finally, the performance of new frequency for each QC item was evaluated using the metric E = O/D. RESULTS One new QC frequency was the same as the old frequency, two new QC frequencies were less than the old ones, and three new QC frequencies were higher than the old ones. For six QC items, E values at the new frequencies were not less than their values at the old frequencies. This indicates that the risk of machine failure is reduced at the new QC frequencies. CONCLUSIONS The application of RM analysis provides a useful tool for determining the optimal frequencies for routine linac QC. This study demonstrated that linac QC can be performed in a way that maintains high performance of the treatment machine in a radiotherapy clinic.
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Affiliation(s)
- Min Ma
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Yan
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghui Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tian
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Men
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Failure modes in stereotactic radiosurgery. A narrative review. Radiography (Lond) 2022; 28:999-1009. [PMID: 35921732 DOI: 10.1016/j.radi.2022.07.007] [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: 11/18/2021] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Stereotactic radiosurgery (SRS) refers to an advanced radiotherapy technique that requires a high level of precision and accuracy and a flawless workflow. Failures within the SRS process can lead to serious consequences due to high doses delivered per treatment. This narrative review aimed to identify the riskiest failure modes (FMs) and the stages at which they occur in the SRS process, as well as the strategies applied to mitigate the risks. It was based on the analysis of published failure mode and effects analysis (FMEA) data. KEY FINDINGS From the literature search in PubMed and Scopus, 7 articles met the eligibility criteria for inclusion in the qualitative synthesis. In total, 9 radiotherapy departments conducted FMEA in the SRS process. 4 of them were community hospitals and 5 were academic centers. Overall, 54 high-risk FMs were identified with treatment planning (FMs: 18), treatment delivery (FMs: 12), consultation and patient registration (FMs: 10) being the riskiest stages. 10 FMs were stereotactic specific, while the remaining 44 could be met in any radiotherapy technique. Failures associated with contouring, medical records review, target reirradiation, and patient positioning were mostly outlined. Risk mitigation strategies included timeouts, double-checks, checklists, training and changes in the working practice. CONCLUSION Our review demonstrated that crucial FMs can occur in all SRS stages. Although generalisations were challenging, the FMs analysis provided a significant source of information about potential high risks and continuous improvement strategies that can be applied both in the SRS and other radiotherapy processes. IMPLICATIONS FOR PRACTICE The results of this research will assist radiotherapy facilities in proactive risk management studies and will allow radiotherapy professionals to reflect on their practice and learn from others' experiences.
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Nishioka S, Okamoto H, Chiba T, Sakasai T, Okuma K, Kuwahara J, Fujiyama D, Nakamura S, Iijima K, Nakayama H, Takemori M, Tsunoda Y, Kaga K, Igaki H. Identifying risk characteristics using failure mode and effect analysis for risk management in online magnetic resonance-guided adaptive radiation therapy. Phys Imaging Radiat Oncol 2022; 23:1-7. [PMID: 35712526 PMCID: PMC9194450 DOI: 10.1016/j.phro.2022.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/15/2022] [Accepted: 06/02/2022] [Indexed: 11/03/2022] Open
Abstract
Failure mode and effect analysis with process map revealed risks. High-risk failure modes and their corrective measures were identified. Hazardous processes and characteristics of the treatment were identified. All failure modes including those identified in previous papers were summarized and compared.
Background and purpose Materials and methods Results Conclusion
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Ahmed S, Bossenberger T, Nalichowski A, Bredfeldt JS, Bartlett S, Bertone K, Dominello M, Dziemianowicz M, Komajda M, Makrigiorgos GM, Marcus KJ, Ng A, Thomas M, Burmeister J. A bi-institutional multi-disciplinary failure mode and effects analysis (FMEA) for a Co-60 based total body irradiation technique. Radiat Oncol 2021; 16:224. [PMID: 34798879 PMCID: PMC8605584 DOI: 10.1186/s13014-021-01894-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We aim to assess the risks associated with total body irradiation (TBI) delivered using a commercial dedicated Co-60 irradiator, and to evaluate inter-institutional and inter-professional variations in the estimation of these risks. METHODS A failure mode and effects analysis (FMEA) was generated using guidance from the AAPM TG-100 report for quantitative estimation of prospective risk metrics. Thirteen radiation oncology professionals from two institutions rated possible failure modes (FMs) for occurrence (O), severity (S), and detectability (D) indices to generate a risk priority number (RPN). The FMs were ranked by descending RPN value. Absolute gross differences (AGD) in resulting RPN values and Jaccard Index (JI; for the top 20 FMs) were calculated. The results were compared between professions and institutions. RESULTS A total of 87 potential FMs (57, 15, 10, 3, and 2 for treatment, quality assurance, planning, simulation, and logistics respectively) were identified and ranked, with individual RPN ranging between 1-420 and mean RPN values ranging between 6 and 74. The two institutions shared 6 of their respective top 20 FMs. For various institutional and professional comparison pairs, the number of common FMs in the top 20 FMs ranged from 6 to 13, with JI values of 18-48%. For the top 20 FMs, the trend in inter-professional variability was institution-specific. The mean AGD values ranged between 12.5 and 74.5 for various comparison pairs. AGD values differed the most for medical physicists (MPs) in comparison to other specialties i.e. radiation oncologists (ROs) and radiation therapists (RTs) [MPs-vs-ROs: 36.3 (standard deviation SD = 34.1); MPs-vs-RTs: 41.2 (SD = 37.9); ROs-vs-RTs: 12.5 (SD = 10.8)]. Trends in inter-professional AGD values were similar for both institutions. CONCLUSION This inter-institutional comparison provides prospective risk analysis for a new treatment delivery unit and illustrates the institution-specific nature of FM prioritization, primarily due to operational differences. Despite being subjective in nature, the FMEA is a valuable tool to ensure the identification of the most significant risks, particularly when implementing a novel treatment modality. The creation of a bi-institutional, multidisciplinary FMEA for this unique TBI technique has not only helped identify potential risks but also served as an opportunity to evaluate clinical and safety practices from the perspective of both multiple professional roles and different institutions.
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Affiliation(s)
- Shahbaz Ahmed
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Todd Bossenberger
- Gershenson Radiation Oncology Center, Karmanos Cancer Center, Detroit, MI, USA
| | - Adrian Nalichowski
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
- Gershenson Radiation Oncology Center, Karmanos Cancer Center, Detroit, MI, USA
| | - Jeremy S Bredfeldt
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Bartlett
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Kristen Bertone
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Michael Dominello
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mark Dziemianowicz
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Melanie Komajda
- Gershenson Radiation Oncology Center, Karmanos Cancer Center, Detroit, MI, USA
| | - G Mike Makrigiorgos
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Karen J Marcus
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Andrea Ng
- Dana Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Marvin Thomas
- Gershenson Radiation Oncology Center, Karmanos Cancer Center, Detroit, MI, USA
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
- Gershenson Radiation Oncology Center, Karmanos Cancer Center, Detroit, MI, USA
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Hilliard EN, Carver RL, Chambers EL, Kavanaugh JA, Erhart KJ, McGuffey AS, Hogstrom KR. Planning and delivery of intensity modulated bolus electron conformal therapy. J Appl Clin Med Phys 2021; 22:8-21. [PMID: 34558774 PMCID: PMC8504596 DOI: 10.1002/acm2.13386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/30/2020] [Accepted: 06/23/2021] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Bolus electron conformal therapy (BECT) is a clinically useful, well-documented, and available technology. The addition of intensity modulation (IM) to BECT reduces volumes of high dose and dose spread in the planning target volume (PTV). This paper demonstrates new techniques for a process that should be suitable for planning and delivering IM-BECT using passive radiotherapy intensity modulation for electrons (PRIME) devices. METHODS The IM-BECT planning and delivery process is an addition to the BECT process that includes intensity modulator design, fabrication, and quality assurance. The intensity modulator (PRIME device) is a hexagonal matrix of small island blocks (tungsten pins of varying diameter) placed inside the patient beam-defining collimator (cutout). Its design process determines a desirable intensity-modulated electron beam during the planning process, then determines the island block configuration to deliver that intensity distribution (segmentation). The intensity modulator is fabricated and quality assurance performed at the factory (.decimal, LLC, Sanford, FL). Clinical quality assurance consists of measuring a fluence distribution in a plane perpendicular to the beam in a water or water-equivalent phantom. This IM-BECT process is described and demonstrated for two sites, postmastectomy chest wall and temple. Dose plans, intensity distributions, fabricated intensity modulators, and quality assurance results are presented. RESULTS IM-BECT plans showed improved D90-10 over BECT plans, 6.4% versus 7.3% and 8.4% versus 11.0% for the postmastectomy chest wall and temple, respectively. Their intensity modulators utilized 61 (single diameter) and 246 (five diameters) tungsten pins, respectively. Dose comparisons for clinical quality assurance showed that for doses greater than 10%, measured agreed with calculated dose within 3% or 0.3 cm distance-to-agreement (DTA) for 99.9% and 100% of points, respectively. CONCLUSION These results demonstrated the feasibility of translating IM-BECT to the clinic using the techniques presented for treatment planning, intensity modulator design and fabrication, and quality assurance processes.
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Affiliation(s)
- Elizabeth N. Hilliard
- Department of Physics and AstronomyLouisiana State UniversityBaton RougeLouisianaUSA
| | - Robert L. Carver
- Department of Physics and AstronomyLouisiana State UniversityBaton RougeLouisianaUSA
- Mary Bird Perkins Cancer CenterBaton RougeLouisianaUSA
| | - Erin L. Chambers
- Department of Physics and AstronomyLouisiana State UniversityBaton RougeLouisianaUSA
| | - James A. Kavanaugh
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | | | - Andrew S. McGuffey
- Department of Physics and AstronomyLouisiana State UniversityBaton RougeLouisianaUSA
| | - Kenneth R. Hogstrom
- Department of Physics and AstronomyLouisiana State UniversityBaton RougeLouisianaUSA
- Mary Bird Perkins Cancer CenterBaton RougeLouisianaUSA
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State of the art in breast intraoperative electron radiation therapy after intraoperative ultrasound introduction. Radiol Oncol 2021; 55:333-340. [PMID: 33991470 PMCID: PMC8366729 DOI: 10.2478/raon-2021-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Breast intraoperative electron radiation therapy (B-IOERT) can be used in clinical practice both as elective irradiation (partial breast irradiation - APBI) in low risk breast cancer patients, and as an anticipated boost. The procedure generally includes the use of a shielding disk between the residual breast and the pectoralis fascia for the protection of the tissues underneath the target volume. The aim of the study was to evaluate the role of intraoperative ultrasound (IOUS) in improving the quality of B-IOERT. PATIENTS AND METHODS B-IOERT was introduced in Trieste in 2012 and its technique was improved in 2014 with IOUS. Both, needle and IOUS were used to measure target thickness and the latter was used even to check the correct position of the shielding disk. The primary endpoint of the study was the evaluation of the effectiveness of IOUS in reducing the risk of a disk misalignment related to B-IOERT and the secondary endpoint was the analysis of acute and late toxicity, by comparing two groups of patients treated with IOERT as a boost, either measured with IOUS and needle (Group 1) or with needle alone (Group 2). Acute and late toxicity were evaluated by validated scoring systems. RESULTS From the institutional patients who were treated between June 2012 and October 2019, 109 were eligible for this study (corresponding to 110 cases, as one patients underwent bilateral conservative surgery and bilateral B-IOERT). Of these, 38 were allocated to group 1 and 72 to group 2. The target thickness measured with the IOUS probe and with the needle were similar (mean difference of 0.1 mm, p = 0.38). The percentage of patients in which the shield was perfectly aligned after IOUS introduction increased from 23% to more than 70%. Moreover, patients treated after IOUS guidance had less acute toxicity (36.8% vs. 48.6%, p = 0.33) from radiation therapy, which reached no statistical significance. Late toxicity turned out to be similar regardless of the use of IOUS guidance: 39.5% vs. 37.5% (p = 0.99). CONCLUSIONS IOUS showed to be accurate in measuring the target depth and decrease the misalignment between collimator and disk. Furthermore there was an absolute decrease in acute toxicity, even though not statistically significant, in the group of women who underwent B-IOERT with IOUS guidance.
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Roles SA, Hepel JT, Leonard KL, Wazer DE, Cardarelli GA, Schwer ML, Saleh ZH, Klein EE, Brindle JM, Rivard MJ. Quantifying risk using FMEA: An alternate approach to AAPM TG-100 for scoring failures and evaluating clinical workflow. Brachytherapy 2021; 20:922-935. [PMID: 33840635 DOI: 10.1016/j.brachy.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Renovation of the brachytherapy program at a leading cancer center utilized methods of the AAPM TG-100 report to objectively evaluate current clinical brachytherapy workflows and develop techniques for minimizing the risk of failures, increasing efficiency, and consequently providing opportunities for improved treatment quality. The TG-100 report guides evaluation of clinical workflows with recommendations for identifying potential failure modes (FM) and scoring them from the perspective of their occurrence frequency O, failure severity S, and inability to detect them D. The current study assessed the impact of differing methods to determine the risk priority number (RPN) beyond simple multiplication. METHODS AND MATERIALS The clinical workflow for a complex brachytherapy procedure was evaluated by a team of 15 staff members, who identified discrete FM using alternate scoring scales than those presented in the TG-100 report. These scales were expanded over all clinically relevant possibilities with care to emphasize mitigation of natural bias for scoring near the median range as well as to enhance the overall scoring-system sensitivity. Based on staff member perceptions, a more realistic measure of risk was determined using weighted functions of their scores. RESULTS This new method expanded the range of RPN possibilities by a factor of 86, improving evaluation and recognition of safe and efficient clinical workflows. Mean RPN values for each FM decreased by 44% when changing from the old to the new clinical workflow, as evaluated using the TG-100 method. This decreased by 66% when evaluated with the new method. As a measure of the total risk associated with an entire clinical workflow, the integral of RPN values increased by 15% and decreased by 31% with the TG-100 and new methods, respectively. CONCLUSIONS This appears to be the first application of an alternate approach to the TG-100 method for evaluating the risk of clinical workflows. It exemplifies the risk analysis techniques necessary to rapidly evaluate simple clinical workflows appropriately.
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Affiliation(s)
- Sean A Roles
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Kara L Leonard
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - David E Wazer
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Gene A Cardarelli
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michelle L Schwer
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Ziad H Saleh
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric E Klein
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - James M Brindle
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Mark J Rivard
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI.
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Hoisak JDP, Manger R, Dragojević I. Benchmarking failure mode and effects analysis of electronic brachytherapy with data from incident learning systems. Brachytherapy 2021; 20:645-654. [PMID: 33353846 DOI: 10.1016/j.brachy.2020.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/12/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Failure modes and effects analysis (FMEA) is a prospective risk assessment tool for identifying failure modes in equipment or processes and informing the design of quality control systems. This work aims to benchmark the performance of FMEAs for electronic brachytherapy (eBT) of the skin and for breast by comparing predicted versus actual failure modes reported in multiple incident learning systems (ILS). METHODS AND MATERIALS Two public and our institution's internal ILS were queried for Xoft Axxent eBT-related events over 9 years. The failure modes and Risk Priority Numbers (RPNs) were taken from FMEAs previously performed for Xoft eBT of nonmelanoma skin cancer and breast intraoperative radiation therapy (IORT). For each event, the treatment site and primary failure mode was compared with the failure modes and RPNs from that site's FMEA. RESULTS 49 events involving Xoft eBT were identified. Thirty-one (63.3%) involved breast IORT, and 18 (36.7%) involved the skin. Three events could not be linked to an FMEA failure mode. In 87.7% of events, the primary failure mode ranked in the FMEA top 10 by RPNs. In 83.3% of skin events, the failure modes ranked in the top 10 by RPN or severity. In 90.3% of IORT events, the failure modes ranked within the top 10 by RPN or severity. CONCLUSIONS Evaluating FMEA failure modes against ILS data demonstrates that FMEA is effective at predicting failure modes but can be dependent on user experience. ILS data can improve FMEA by identifying potential failure modes and suggesting realistic occurrence, detectability, and severity values.
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Affiliation(s)
- Jeremy D P Hoisak
- Department of Radiation Medicine & Applied Sciences, UC San Diego, La Jolla, CA.
| | - Ryan Manger
- Department of Radiation Medicine & Applied Sciences, UC San Diego, La Jolla, CA
| | - Irena Dragojević
- Department of Radiation Medicine & Applied Sciences, UC San Diego, La Jolla, CA
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11
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Liu HC, Zhang LJ, Ping YJ, Wang L. Failure mode and effects analysis for proactive healthcare risk evaluation: A systematic literature review. J Eval Clin Pract 2020; 26:1320-1337. [PMID: 31849153 DOI: 10.1111/jep.13317] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 10/08/2019] [Accepted: 10/28/2019] [Indexed: 12/23/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Failure mode and effects analysis (FMEA) is a valuable reliability management tool that can preemptively identify the potential failures of a system and assess their causes and effects, thereby preventing them from occurring. The use of FMEA in the healthcare setting has become increasingly popular over the last decade, being applied to a multitude of different areas. The objective of this study is to review comprehensively the literature regarding the application of FMEA for healthcare risk analysis. METHODS An extensive search was carried out in the scholarly databases of Scopus and PubMed, and we only chose the academic articles which used the FMEA technique to solve healthcare risk analysis problems. Furthermore, a bibliometric analysis was performed based on the number of citations, publication year, appeared journals, authors, and country of origin. RESULTS A total of 158 journal papers published over the period of 1998 to 2018 were extracted and reviewed. These publications were classified into four categories (ie, healthcare process, hospital management, hospital informatization, and medical equipment and production) according to the healthcare issues to be solved, and analyzed regarding the application fields and the utilized FMEA methods. CONCLUSION FMEA has high practicality for healthcare quality improvement and error reduction and has been prevalently employed to improve healthcare processes in hospitals. This research supports academics and practitioners in effectively adopting the FMEA tool to proactively reduce healthcare risks and increase patient safety, and provides an insight into its state-of-the-art.
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Affiliation(s)
- Hu-Chen Liu
- School of Economics and Management, Tongji University, Shanghai, People's Republic of China.,College of Economics and Management, China Jiliang University, Hangzhou, People'sRepublic of China
| | - Li-Jun Zhang
- School of Management, Shanghai University, Shanghai, People's Republic of China
| | - Ye-Jia Ping
- School of Management, Shanghai University, Shanghai, People's Republic of China
| | - Liang Wang
- School of Management, Shanghai University, Shanghai, People's Republic of China
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12
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Becker SJ, Niu Y, Mutaf Y, Chen S, Poirier Y, Nichols EM, Yi B. Development and validation of a comprehensive patient-specific quality assurance program for a novel stereotactic radiation delivery system for breast lesions. J Appl Clin Med Phys 2019; 20:138-148. [PMID: 31833640 PMCID: PMC6909122 DOI: 10.1002/acm2.12778] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 10/18/2019] [Accepted: 10/20/2019] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The GammaPod is a dedicated prone breast stereotactic radiosurgery (SRS) machine composed of 25 cobalt-60 sources which rotate around the breast to create highly conformal dose distributions for boosts, partial-breast irradiation, or neo-adjuvant SRS. We describe the development and validation of a patient-specific quality assurance (PSQA) system for the GammaPod. METHODS We present two PSQA methods: measurement based and calculation based PSQA. The measurements are performed with a combination of absolute and relative dose measurements. Absolute dosimetry is performed in a single point using a 0.053-cc pinpoint ionization chamber in the center of a polymethylmethacrylate (PMMA) breast phantom and a water-filled breast cup. Relative dose distributions are verified with EBT3 film in the PMMA phantom. The calculation-based method verifies point doses with a novel semi-empirical independent-calculation software. RESULTS The average (± standard deviation) breast and target sizes were 1263 ± 335.3 cc and 66.9 ± 29.9 cc, respectively. All ion chamber measurements performed in water and the PMMA phantom agreed with the treatment planning system (TPS) within 2.7%, with average (max) difference of -1.3% (-1.9%) and -1.3% (-2.7%), respectively. Relative dose distributions measured by film showed an average gamma pass rate of 97.0 ± 3.2 when using a 3%/1 mm criteria. The lowest gamma analysis pass rate was 90.0%. The independent calculation software had average agreements (max) with the patient and QA plan calculation of 0.2% (2.2%) and -0.1% (2.0%), respectively. CONCLUSION We successfully implemented the first GammaPod PSQA program. These results show that the GammaPod can be used to calculate and deliver the predicted dose precisely and accurately. For routine PSQA performed prior to treatments, the independent calculation is recommended as it verifies the accuracy of the planned dose without increasing the risk of losing vacuum due to prolonged waiting times.
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Affiliation(s)
- Stewart J. Becker
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Ying Niu
- MedStar Georgetown University HospitalWashingtonDCUSA
| | - Yildirim Mutaf
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Shifeng Chen
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Yannick Poirier
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Elizabeth M. Nichols
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - ByongYong Yi
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
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13
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Risk analysis of electronic intraoperative radiation therapy for breast cancer. Brachytherapy 2019; 18:271-276. [DOI: 10.1016/j.brachy.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/22/2022]
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14
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Bonfantini F, Giandini T, Meroni S, Cavallo A, Stucchi C, Carrara M, Mongioj V, Veronese I, Pignoli E. Application of failure mode and effects analysis to optimization of linac quality controls protocol. Med Phys 2019; 46:2541-2555. [DOI: 10.1002/mp.13538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 01/31/2019] [Accepted: 03/27/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francesca Bonfantini
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Tommaso Giandini
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Silvia Meroni
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Anna Cavallo
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Claudio Stucchi
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Mauro Carrara
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Valeria Mongioj
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
| | - Ivan Veronese
- Physics Department Università degli Studi di Milano and Istituto Nazionale di Fisica Nucleare Sezione di Milano Via Giovanni Celoria 16 20133 Milan Italy
| | - Emanuele Pignoli
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori via Venezian 1 20133 MilanItaly
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15
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Alhamada H, Simon S, Philippson C, Vandekerkhove C, Jourani Y, Pauly N, Dubus A, Reynaert N. Shielding disk position in intra-operative electron radiotherapy (IOERT): A Monte Carlo study. Phys Med 2018; 51:1-6. [PMID: 30278980 DOI: 10.1016/j.ejmp.2018.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/30/2018] [Accepted: 05/25/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In IOERT breast treatments, a shielding disk is frequently used to protect the underlying healthy structures. The disk is usually composed of two materials, a low-Z material intended to be oriented towards the beam and a high-Z material. As tissues are repositioned around the shield before treatment, the disk is no longer visible and its correct alignment with respect to the beam is guaranteed. This paper studies the dosimetric characteristics of four possible clinical positioning scenarios of the shielding disk. A new alignment method for the shielding disk in the beam is introduced. Finally, it suggests a new design for the shielding disk. METHODS As the first step, the IOERT machine "Mobetron 1000" was modeled by using Monte Carlo simulation, tuning the MC model until an excellent match with the measured PDDs and profiles was achieved. Four possible shielding disk positioning scenarios were considered, determining the dosimetric impact. Furthermore, in our center, to prevent beam misalignment, we have developed a shielding disk equipped with guiding rods. Having ascertained a correct alignment between the disk and the beam, we can propose a new internal design of the shielding disk that can improve the dose distribution with a better coverage of the treated area. RESULTS All MC simulations were performed with a 12 MeV beam, the maximum energy of Mobetron 1000 and a 5.5 cm diameter flat tip applicator, this applicator being the most clinically used. The simulations were compared with measurements performed in a water phantom and showed good results within 2.2% of root mean square difference (RMSD). The misplacement positions of the shielding disk have dosimetric impacts in the treatment volume and a small translation could have a significant influence on healthy tissues. The D-scenario is the worst which could happens when the shielding disk is flipped upside down, giving up to 144% dose instead of 90% at the surface of the Pb/Al shielding disk. A new shielding design used, together with our alignment tool, is able to give a more homogeneous dose in the target area. CONCLUSIONS The accuracy of shielding disk position can still be problematic in IOERT dosimetry. Any method that can ascertain the good alignment between the shielding disk and the beam is beneficial for the dose distribution and is a prerequisite for an optimized shield internal design that could improve the coverage of the treated area and the protection of healthy tissues.
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Affiliation(s)
- Husein Alhamada
- Nuclear Metrology, Ecole Polytechnique, Universite Libre de Bryxellers, Belgium.
| | - Stephane Simon
- Radiotherapy Department, Institute Jules Bordet, Belgium.
| | | | | | - Younes Jourani
- Radiotherapy Department, Institute Jules Bordet, Belgium.
| | - Nicolas Pauly
- Nuclear Metrology, Ecole Polytechnique, Universite Libre de Bryxellers, Belgium.
| | - Alain Dubus
- Nuclear Metrology, Ecole Polytechnique, Universite Libre de Bryxellers, Belgium.
| | - Nick Reynaert
- Radiotherapy Department, Institute Jules Bordet, Belgium.
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16
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Evaluation of dosimetric properties of shielding disk used in intraoperative electron radiotherapy: A Monte Carlo study. Appl Radiat Isot 2018; 139:107-113. [DOI: 10.1016/j.apradiso.2018.04.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 02/26/2018] [Accepted: 04/30/2018] [Indexed: 11/18/2022]
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17
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A risk-based approach to development of ultrasound-based high-dose-rate prostate brachytherapy quality management. Brachytherapy 2018; 17:788-793. [DOI: 10.1016/j.brachy.2018.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/15/2018] [Accepted: 05/23/2018] [Indexed: 11/22/2022]
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18
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Implementation of failure mode and effective analysis for high dose rate brachytherapy at Tata Memorial Hospital, Mumbai, India. Cancer Radiother 2018; 22:334-340. [DOI: 10.1016/j.canrad.2018.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 05/15/2018] [Indexed: 10/14/2022]
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19
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Kamomae T, Monzen H, Kawamura M, Okudaira K, Nakaya T, Mukoyama T, Miyake Y, Ishihara Y, Itoh Y, Naganawa S. Dosimetric feasibility of using tungsten-based functional paper for flexible chest wall protectors in intraoperative electron radiotherapy for breast cancer. Phys Med Biol 2017; 63:015006. [PMID: 29083315 DOI: 10.1088/1361-6560/aa96cf] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intraoperative electron radiotherapy (IOERT), which is an accelerated partial breast irradiation method, has been used for early-stage breast cancer treatment. In IOERT, a protective disk is inserted behind the target volume to minimize the dose received by normal tissues. However, to use such a disk, the surgical incision must be larger than the field size because the disk is manufactured from stiff and unyielding materials. In this study, the applicability of newly developed tungsten-based functional paper (TFP) was assessed as an alternative to the existing protective disk. The radiation-shielding performance of the TFP was verified through experimental measurements and Monte Carlo simulations. Percentage depth dose curves and lateral dose profiles with and without TFPs were measured and simulated on a dedicated IOERT accelerator. The number of piled-up TFPs was changed from 1 to 40. In the experimental measurements, the relative doses at the exit plane of the TFPs for 9 MeV were 42.7%, 9.2%, 0.2%, and 0.1% with 10, 20, 30, and 40 TFPs, respectively, whereas those for 12 MeV were 63.6%, 27.1%, 8.6%, and 0.2% with 10, 20, 30, and 40 TFPs, respectively. Slight dose enhancements caused by backscatter radiation from the TFPs were observed at the entrance plane of the TFPs at both beam energies. The results of the Monte Carlo simulation indicated the same tendency as the experimental measurements. Based on the experimental and simulated results, the radiation-shielding performances of 30 TFPs for 9 MeV and 40 TFPs for 12 MeV were confirmed to be acceptable and close to those of the existing protective disk. The findings of this study suggest the feasibility of using TFPs as flexible chest wall protectors in IOERT for breast cancer treatment.
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Affiliation(s)
- Takeshi Kamomae
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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20
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In vivo dosimetry with MOSFETs and GAFCHROMIC films during electron IORT for Accelerated Partial Breast Irradiation. Phys Med 2017; 44:26-33. [DOI: 10.1016/j.ejmp.2017.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/19/2017] [Accepted: 11/04/2017] [Indexed: 11/22/2022] Open
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21
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Faught JT, Balter PA, Johnson JL, Kry SF, Court LE, Stingo FC, Followill DS. An FMEA evaluation of intensity modulated radiation therapy dose delivery failures at tolerance criteria levels. Med Phys 2017; 44:5575-5583. [PMID: 28862765 DOI: 10.1002/mp.12551] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/25/2017] [Accepted: 08/06/2017] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The objective of this work was to assess both the perception of failure modes in Intensity Modulated Radiation Therapy (IMRT) when the linac is operated at the edge of tolerances given in AAPM TG-40 (Kutcher et al.) and TG-142 (Klein et al.) as well as the application of FMEA to this specific section of the IMRT process. METHODS An online survey was distributed to approximately 2000 physicists worldwide that participate in quality services provided by the Imaging and Radiation Oncology Core - Houston (IROC-H). The survey briefly described eleven different failure modes covered by basic quality assurance in step-and-shoot IMRT at or near TG-40 (Kutcher et al.) and TG-142 (Klein et al.) tolerance criteria levels. Respondents were asked to estimate the worst case scenario percent dose error that could be caused by each of these failure modes in a head and neck patient as well as the FMEA scores: Occurrence, Detectability, and Severity. Risk probability number (RPN) scores were calculated as the product of these scores. Demographic data were also collected. RESULTS A total of 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5 to 45 yr (average 18 yr). A total of 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems, and linear accelerator manufacturers were represented. All failure modes received widely varying scores ranging from 1 to 10 for occurrence, at least 1-9 for detectability, and at least 1-7 for severity. Ranking failure modes by RPN scores also resulted in large variability, with each failure mode being ranked both most risky (1st) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (P < 0.01) for each FM as expected. No universal correlations were found between the demographic information collected and scoring, percent dose errors or ranking. CONCLUSIONS Failure modes investigated overall were evaluated as low to medium risk, with average RPNs less than 110. The ranking of 11 failure modes was not agreed upon by the community. Large variability in FMEA scoring may be caused by individual interpretation and/or experience, reflecting the subjective nature of the FMEA tool.
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Affiliation(s)
- Jacqueline Tonigan Faught
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,IROC Houston QA Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Peter A Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jennifer L Johnson
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Stephen F Kry
- IROC Houston QA Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Francesco C Stingo
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Statistics, Computing, Applications, University of Florence, 50121, Florence, Italy
| | - David S Followill
- IROC Houston QA Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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22
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Harry T, Yaddanapudi S, Cai B, Stinson K, Murty Goddu S, Noel C, Mutic S, Pawlicki T. Risk assessment of a new acceptance testing procedure for conventional linear accelerators. Med Phys 2017; 44:5610-5616. [DOI: 10.1002/mp.12527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/09/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- Taylor Harry
- Department of Radiation Medicine and Applied Sciences; University of California San Diego; 3855 Health Sciences Dr La Jolla CA 92093 USA
| | - Sridhar Yaddanapudi
- Department of Radiation Oncology; Washington University School of Medicine; 4921 Parkview Pl St. Louis MO 63110 USA
| | - Bin Cai
- Department of Radiation Oncology; Washington University School of Medicine; 4921 Parkview Pl St. Louis MO 63110 USA
| | - Keith Stinson
- Varian Medical Systems; 3100 Hansen Way Palo Alto CA 94304 USA
| | - S. Murty Goddu
- Department of Radiation Oncology; Washington University School of Medicine; 4921 Parkview Pl St. Louis MO 63110 USA
| | - Camille Noel
- Department of Radiation Oncology; Washington University School of Medicine; 4921 Parkview Pl St. Louis MO 63110 USA
| | - Sasa Mutic
- Department of Radiation Oncology; Washington University School of Medicine; 4921 Parkview Pl St. Louis MO 63110 USA
| | - Todd Pawlicki
- Department of Radiation Medicine and Applied Sciences; University of California San Diego; 3855 Health Sciences Dr La Jolla CA 92093 USA
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23
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Schuller BW, Burns A, Ceilley EA, King A, LeTourneau J, Markovic A, Sterkel L, Taplin B, Wanner J, Albert JM. Failure mode and effects analysis: A community practice perspective. J Appl Clin Med Phys 2017; 18:258-267. [PMID: 28944980 PMCID: PMC5689935 DOI: 10.1002/acm2.12190] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 07/27/2017] [Accepted: 08/01/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To report our early experiences with failure mode and effects analysis (FMEA) in a community practice setting. METHODS The FMEA facilitator received extensive training at the AAPM Summer School. Early efforts focused on department education and emphasized the need for process evaluation in the context of high profile radiation therapy accidents. A multidisciplinary team was assembled with representation from each of the major department disciplines. Stereotactic radiosurgery (SRS) was identified as the most appropriate treatment technique for the first FMEA evaluation, as it is largely self-contained and has the potential to produce high impact failure modes. Process mapping was completed using breakout sessions, and then compiled into a simple electronic format. Weekly sessions were used to complete the FMEA evaluation. Risk priority number (RPN) values > 100 or severity scores of 9 or 10 were considered high risk. The overall time commitment was also tracked. RESULTS The final SRS process map contained 15 major process steps and 183 subprocess steps. Splitting the process map into individual assignments was a successful strategy for our group. The process map was designed to contain enough detail such that another radiation oncology team would be able to perform our procedures. Continuous facilitator involvement helped maintain consistent scoring during FMEA. Practice changes were made responding to the highest RPN scores, and new resulting RPN scores were below our high-risk threshold. The estimated person-hour equivalent for project completion was 258 hr. CONCLUSIONS This report provides important details on the initial steps we took to complete our first FMEA, providing guidance for community practices seeking to incorporate this process into their quality assurance (QA) program. Determining the feasibility of implementing complex QA processes into different practice settings will take on increasing significance as the field of radiation oncology transitions into the new TG-100 QA paradigm.
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Affiliation(s)
- Bradley W Schuller
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Angi Burns
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Elizabeth A Ceilley
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Alan King
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Joan LeTourneau
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Alexander Markovic
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Lynda Sterkel
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Brigid Taplin
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Jennifer Wanner
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
| | - Jeffrey M Albert
- Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO, USA
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24
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Vidali C, Severgnini M, Urbani M, Toscano L, Perulli A, Bortul M. FMECA Application to Intraoperative Electron Beam Radiotherapy Procedure As a Quality Method to Prevent and Reduce Patient's Risk in Conservative Surgery for Breast Cancer. Front Med (Lausanne) 2017; 4:138. [PMID: 28894737 PMCID: PMC5581388 DOI: 10.3389/fmed.2017.00138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/02/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Failure Mode Effects and Criticalities Analysis (FMECA) represents a prospective method for risk assessment in complex medical practices. Our objective was to describe the application of FMECA approach to intraoperative electron beam radiotherapy (IOERT), delivered using a mobile linear accelerator, for the treatment of early breast cancer as an anticipated boost. MATERIALS AND METHODS A multidisciplinary Working Group, including several different professional profiles, was created before the beginning of clinical practice in 2012, with the purpose of writing the Flow Chart and applying the FMECA methodology to IOERT procedure. Several criticalities were identified a priori in the different steps of the procedure and a list of all potential failure modes (FMs) was drafted and ranked using the risk priority number (RPN) scoring system, based on the product of three parameters: severity, occurrence, and detectability (score between 1 and 5). The actions aimed at reducing the risk were then defined by the Working Group and the risk analysis was repeated in 2014 and in 2016, in order to assess the improvement achieved. RESULTS Fifty-one FMs were identified, which represented the issues prospectively investigated according to the FMECA methodology. Considering a set threshold of 30, the evaluated RPNs show that 33 out of 51 FMs are critical; 6 are included in the moderate risk class (RPN: 31-40); 16 in the intermediate risk class (RPN: 41-50), and 11 in the high risk class (RPN: >50). DISCUSSION The most critical steps concerned the surgical procedure and IOERT set-up. The introduction of the corrective actions into the clinical practice achieved the reduction of the RPNs in the re-analysis of the FMECA worksheet after 2 and 4 years, respectively. CONCLUSION FMECA proved to be a useful tool for prospective evaluation of potential failures in IOERT and contributed to optimize patient safety and to improve risk management culture among all the professionals of the Working Group.
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Affiliation(s)
- Cristiana Vidali
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Mara Severgnini
- Department of Medical Physics, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Monica Urbani
- Department of Surgery, University of Trieste, Trieste, Italy
| | - Licia Toscano
- Department of Physics, University of Trieste, Trieste, Italy
| | - Alfredo Perulli
- Department of Medical Direction, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Marina Bortul
- Department of Surgery, University of Trieste, Trieste, Italy
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25
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Rah JE, Manger RP, Yock AD, Kim GY. A comparison of two prospective risk analysis methods: Traditional FMEA and a modified healthcare FMEA. Med Phys 2017; 43:6347. [PMID: 27908165 DOI: 10.1118/1.4966129] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To examine the abilities of a traditional failure mode and effects analysis (FMEA) and modified healthcare FMEA (m-HFMEA) scoring methods by comparing the degree of congruence in identifying high risk failures. METHODS The authors applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation were based on the risk priority number (RPN). The RPN is a product of three indices: occurrence, severity, and detectability. The m-HFMEA approach utilized two indices, severity and frequency. A risk inventory matrix was divided into four categories: very low, low, high, and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. RESULTS The two methods were independently compared to determine if the results and rated risks matched. The authors' results showed an agreement of 85% between FMEA and m-HFMEA approaches for top 20 risks of SIG-RS-specific failure modes. The main differences between the two approaches were the distribution of the values and the observation that failure modes (52, 54, 154) with high m-HFMEA scores do not necessarily have high FMEA-RPN scores. In the m-HFMEA analysis, when the risk score is determined, the basis of the established HFMEA Decision Tree™ or the failure mode should be more thoroughly investigated. CONCLUSIONS m-HFMEA is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allows the prioritization of high risks and mitigation measures. It is therefore a useful tool for the prospective risk analysis method to radiotherapy.
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Affiliation(s)
- Jeong-Eun Rah
- Department of Radiation Oncology, Myongji Hospital, Goyang 10475, South Korea
| | - Ryan P Manger
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, California 92093
| | - Adam D Yock
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, California 92093
| | - Gwe-Ya Kim
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, California 92093
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O'Daniel JC, Yin FF. Quantitative Approach to Failure Mode and Effect Analysis for Linear Accelerator Quality Assurance. Int J Radiat Oncol Biol Phys 2017; 98:56-62. [PMID: 28587053 DOI: 10.1016/j.ijrobp.2017.01.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/21/2016] [Accepted: 01/13/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine clinic-specific linear accelerator quality assurance (QA) TG-142 test frequencies, to maximize physicist time efficiency and patient treatment quality. METHODS AND MATERIALS A novel quantitative approach to failure mode and effect analysis is proposed. Nine linear accelerator-years of QA records provided data on failure occurrence rates. The severity of test failure was modeled by introducing corresponding errors into head and neck intensity modulated radiation therapy treatment plans. The relative risk of daily linear accelerator QA was calculated as a function of frequency of test performance. RESULTS Although the failure severity was greatest for daily imaging QA (imaging vs treatment isocenter and imaging positioning/repositioning), the failure occurrence rate was greatest for output and laser testing. The composite ranking results suggest that performing output and lasers tests daily, imaging versus treatment isocenter and imaging positioning/repositioning tests weekly, and optical distance indicator and jaws versus light field tests biweekly would be acceptable for non-stereotactic radiosurgery/stereotactic body radiation therapy linear accelerators. CONCLUSIONS Failure mode and effect analysis is a useful tool to determine the relative importance of QA tests from TG-142. Because there are practical time limitations on how many QA tests can be performed, this analysis highlights which tests are the most important and suggests the frequency of testing based on each test's risk priority number.
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Affiliation(s)
- Jennifer C O'Daniel
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Failure mode and effects analysis of skin electronic brachytherapy using Esteya ® unit. J Contemp Brachytherapy 2016; 8:518-524. [PMID: 28115958 PMCID: PMC5241381 DOI: 10.5114/jcb.2016.64745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 11/17/2016] [Indexed: 01/21/2023] Open
Abstract
Purpose Esteya® (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden) is an electronic brachytherapy device used for skin cancer lesion treatment. In order to establish an adequate level of quality of treatment, a risk analysis of the Esteya treatment process has been done, following the methodology proposed by the TG-100 guidelines of the American Association of Physicists in Medicine (AAPM). Material and methods A multidisciplinary team familiar with the treatment process was formed. This team developed a process map (PM) outlining the stages, through which a patient passed when subjected to the Esteya treatment. They identified potential failure modes (FM) and each individual FM was assessed for the severity (S), frequency of occurrence (O), and lack of detection (D). A list of existing quality management tools was developed and the FMs were consensually reevaluated. Finally, the FMs were ranked according to their risk priority number (RPN) and their S. Results 146 FMs were identified, 106 of which had RPN ≥ 50 and 30 had S ≥ 7. After introducing the quality management tools, only 21 FMs had RPN ≥ 50. The importance of ensuring contact between the applicator and the surface of the patient’s skin was emphasized, so the setup was reviewed by a second individual before each treatment session with periodic quality control to ensure stability of the applicator pressure. Some of the essential quality management tools are already being implemented in the installation are the simple templates for reproducible positioning of skin applicators, that help marking the treatment area and positioning of X-ray tube. Conclusions New quality management tools have been established as a result of the application of the failure modes and effects analysis (FMEA) treatment. However, periodic update of the FMEA process is necessary, since clinical experience has suggested occurring of further new possible potential failure modes.
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Teixeira FC, de Almeida CE, Saiful Huq M. Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil. Med Phys 2016; 43:171. [PMID: 26745909 DOI: 10.1118/1.4938065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. METHODS The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of risk priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. RESULTS The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. CONCLUSIONS The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different radiotherapy centers. Integrated approaches to device-centric and process specific quality management program specific to each radiotherapy center are the key to a safe quality management program.
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Affiliation(s)
- Flavia C Teixeira
- CNEN-Comissao Nacional de Energia Nuclear, Rio de Janeiro, RJ 22290-901, Brazil and LCR/UERJ-Laboratorio de Ciencias Radiologicas/Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ 20550-013, Brazil
| | - Carlos E de Almeida
- LCR/UERJ-Laboratorio de Ciencias Radiologicas/Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ 20550-013, Brazil
| | - M Saiful Huq
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute and UPMC Cancer Center, Pittsburgh, Pennsylvania 15232
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Giardina M, Cantone MC, Tomarchio E, Veronese I. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. HEALTH PHYSICS 2016; 111:317-326. [PMID: 27575344 DOI: 10.1097/hp.0000000000000536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper presents a review of risk analyses in radiotherapy (RT) processes carried out by using Healthcare Failure Mode Effect Analysis (HFMEA) methodology, a qualitative method that proactively identifies risks to patients and corrects medical errors before they occur. This literature review was performed to provide an overview of how to approach the development of HFMEA applications in modern RT procedures, comparing recently published research conducted to support proactive programs to identify risks. On the basis of the reviewed literature, the paper suggests HFMEA shortcomings that need to be addressed.
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Affiliation(s)
- M Giardina
- *Department of Energy, Information Engineering and Mathematical Models (DEIM), University of Palermo, Viale delle Scienze, Edificio 6, 90128 Palermo, Italy; †Università degli Studi di Milano, Scienze Biomediche, Chirurgiche e Odontoiatriche, and INFN, Sezione di Milano, Via Pascal 36, 20133 Milano, Italy; ‡Università degli Studi di Milano, Dipartimento di Fisica, and INFN, Sezione di Milano, Via Celoria 16, 20133, Milano, Italy
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Wadi-Ramahi S, Alnajjar W, Mahmood R, Jastaniyah N, Moftah B. Failure modes and effects analysis in image-guided high-dose-rate brachytherapy: Quality control optimization to reduce errors in treatment volume. Brachytherapy 2016; 15:669-78. [DOI: 10.1016/j.brachy.2016.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/06/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
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Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF, Yorke ED. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Med Phys 2016; 43:4209. [PMID: 27370140 PMCID: PMC4985013 DOI: 10.1118/1.4947547] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 12/25/2022] Open
Abstract
The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for "intensity modulated radiation therapy (IMRT)" as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.
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Affiliation(s)
- M Saiful Huq
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute and UPMC CancerCenter, Pittsburgh, Pennsylvania 15232
| | - Benedick A Fraass
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | - Peter B Dunscombe
- Department of Oncology, University of Calgary, Calgary T2N 1N4, Canada
| | | | - Geoffrey S Ibbott
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas 77030
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California 92093-0843
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, P.O. Box 980058, Richmond, Virginia 23298
| | - Frank Rath
- Department of Engineering Professional Development, University of Wisconsin, Madison, Wisconsin 53706
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin 53705-2275
| | - Jeffrey F Williamson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298-0058
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Center, New York, New York 10065
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Zheng Y, Johnson R, Larson G. Minimizing treatment planning errors in proton therapy using failure mode and effects analysis. Med Phys 2016; 43:2904-2910. [PMID: 27277039 DOI: 10.1118/1.4948686] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. METHODS The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authors estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. RESULTS In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. CONCLUSIONS The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error reduction in proton treatment planning, thus improving the effectiveness and safety of proton therapy.
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Affiliation(s)
- Yuanshui Zheng
- ProCure Proton Therapy Center, 5901 W Memorial Road, Oklahoma City, Oklahoma 73142 and Department of Physics, Oklahoma State University, Stillwater, Oklahoma 74078-3072
| | - Randall Johnson
- ProCure Proton Therapy Center, 5901 W Memorial Road, Oklahoma City, Oklahoma 73142
| | - Gary Larson
- ProCure Proton Therapy Center, 5901 W Memorial Road, Oklahoma City, Oklahoma 73142
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Yang F, Cao N, Young L, Howard J, Logan W, Arbuckle T, Sponseller P, Korssjoen T, Meyer J, Ford E. Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy. Med Phys 2016; 42:2777-85. [PMID: 26127030 DOI: 10.1118/1.4919440] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. METHODS FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. RESULTS FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). CONCLUSIONS FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.
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Affiliation(s)
- F Yang
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - N Cao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - L Young
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - J Howard
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - W Logan
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - T Arbuckle
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - P Sponseller
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - T Korssjoen
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - J Meyer
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
| | - E Ford
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington 98195
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Pawlicki T, Samost A, Brown DW, Manger RP, Kim G, Leveson NG. Application of systems and control theory‐based hazard analysis to radiation oncology. Med Phys 2016; 43:1514-30. [DOI: 10.1118/1.4942384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Todd Pawlicki
- Department of Radiation Medicine and Applied Sciences, UC San Diego, 3385 Health Sciences Drive, La Jolla, California 92093
| | - Aubrey Samost
- Engineering Systems Division, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02142
| | - Derek W. Brown
- Department of Radiation Medicine and Applied Sciences, UC San Diego, 3385 Health Sciences Drive, La Jolla, California 92093
| | - Ryan P. Manger
- Department of Radiation Medicine and Applied Sciences, UC San Diego, 3385 Health Sciences Drive, La Jolla, California 92093
| | - Gwe‐Ya Kim
- Department of Radiation Medicine and Applied Sciences, UC San Diego, 3385 Health Sciences Drive, La Jolla, California 92093
| | - Nancy G. Leveson
- Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02142
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McElroy LM, Khorzad R, Nannicelli AP, Brown AR, Ladner DP, Holl JL. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf 2015; 25:329-36. [PMID: 26170336 DOI: 10.1136/bmjqs-2015-004130] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/21/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Failure mode and effects analysis (FMEA) is a method of risk assessment increasingly used in healthcare over the past decade. The traditional method, however, can require substantial time and training resources. The goal of this study is to compare a simplified scoring method with the traditional scoring method to determine the degree of congruence in identifying high-risk failures. METHODS An FMEA of the operating room (OR) to intensive care unit (ICU) handoff was conducted. Failures were scored and ranked using both the traditional risk priority number (RPN) and criticality-based method, and a simplified method, which designates failures as 'high', 'medium' or 'low' risk. The degree of congruence was determined by first identifying those failures determined to be critical by the traditional method (RPN≥300), and then calculating the per cent congruence with those failures designated critical by the simplified methods (high risk). RESULTS In total, 79 process failures among 37 individual steps in the OR to ICU handoff process were identified. The traditional method yielded Criticality Indices (CIs) ranging from 18 to 72 and RPNs ranging from 80 to 504. The simplified method ranked 11 failures as 'low risk', 30 as medium risk and 22 as high risk. The traditional method yielded 24 failures with an RPN ≥300, of which 22 were identified as high risk by the simplified method (92% agreement). The top 20% of CI (≥60) included 12 failures, of which six were designated as high risk by the simplified method (50% agreement). CONCLUSIONS These results suggest that the simplified method of scoring and ranking failures identified by an FMEA can be a useful tool for healthcare organisations with limited access to FMEA expertise. However, the simplified method does not result in the same degree of discrimination in the ranking of failures offered by the traditional method.
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Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Rebeca Khorzad
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Anna P Nannicelli
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alexandra R Brown
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
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Veronese I, De Martin E, Martinotti AS, Fumagalli ML, Vite C, Redaelli I, Malatesta T, Mancosu P, Beltramo G, Fariselli L, Cantone MC. Multi-institutional application of Failure Mode and Effects Analysis (FMEA) to CyberKnife Stereotactic Body Radiation Therapy (SBRT). Radiat Oncol 2015; 10:132. [PMID: 26071401 PMCID: PMC4469574 DOI: 10.1186/s13014-015-0438-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/09/2015] [Indexed: 12/31/2022] Open
Abstract
Background A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to assess the risks for patients undergoing Stereotactic Body Radiation Therapy (SBRT) treatments for lesions located in spine and liver in two CyberKnife® Centres. Methods The various sub-processes characterizing the SBRT treatment were identified to generate the process trees of both the treatment planning and delivery phases. This analysis drove to the identification and subsequent scoring of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system. Novel solutions aimed to increase patient safety were accordingly considered. Results The process-tree characterising the SBRT treatment planning stage was composed with a total of 48 sub-processes. Similarly, 42 sub-processes were identified in the stage of delivery to liver tumours and 30 in the stage of delivery to spine lesions. All the sub-processes were judged to be potentially prone to one or more failure modes. Nineteen failures (i.e. 5 in treatment planning stage, 5 in the delivery to liver lesions and 9 in the delivery to spine lesions) were considered of high concern in view of the high RPN and/or severity index value. Conclusions The analysis of the potential failures, their causes and effects allowed to improve the safety strategies already adopted in the clinical practice with additional measures for optimizing quality management workflow and increasing patient safety.
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Affiliation(s)
- Ivan Veronese
- Dipartimento di Fisica, Università degli Studi di Milano, Via Celoria 16, Milan, 20133, Italy.
| | - Elena De Martin
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, UO Direzione Sanitaria, Milan, Italy.
| | | | - Maria Luisa Fumagalli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, UO Direzione Sanitaria, Milan, Italy.
| | - Cristina Vite
- Centro Diagnostico Italiano, Reparto Cyberknife, Milan, Italy. .,Present address; Now at: Clinica Luganese, Lugano, Switzerland.
| | - Irene Redaelli
- Centro Diagnostico Italiano, Reparto Cyberknife, Milan, Italy.
| | - Tiziana Malatesta
- Ospedale San Giovanni Calibita Fatebenefratelli, UOC Fisica Sanitaria AFAR, Rome, Italy.
| | - Pietro Mancosu
- Reparto di Radioterapia Oncologica, Istituto Clinico Humanitas, Milan, Italy.
| | | | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy.
| | - Marie Claire Cantone
- Dipartimento di Fisica, Università degli Studi di Milano, Via Celoria 16, Milan, 20133, Italy.
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Xiao Y, Kry SF, Popple R, Yorke E, Papanikolaou N, Stathakis S, Xia P, Huq S, Bayouth J, Galvin J, Yin FF. Flattening filter-free accelerators: a report from the AAPM Therapy Emerging Technology Assessment Work Group. J Appl Clin Med Phys 2015; 16:5219. [PMID: 26103482 PMCID: PMC5690108 DOI: 10.1120/jacmp.v16i3.5219] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/06/2015] [Accepted: 01/23/2015] [Indexed: 11/23/2022] Open
Abstract
This report describes the current state of flattening filter‐free (FFF) radiotherapy beams implemented on conventional linear accelerators, and is aimed primarily at practicing medical physicists. The Therapy Emerging Technology Assessment Work Group of the American Association of Physicists in Medicine (AAPM) formed a writing group to assess FFF technology. The published literature on FFF technology was reviewed, along with technical specifications provided by vendors. Based on this information, supplemented by the clinical experience of the group members, consensus guidelines and recommendations for implementation of FFF technology were developed. Areas in need of further investigation were identified. Removing the flattening filter increases beam intensity, especially near the central axis. Increased intensity reduces treatment time, especially for high‐dose stereotactic radiotherapy/radiosurgery (SRT/SRS). Furthermore, removing the flattening filter reduces out‐of‐field dose and improves beam modeling accuracy. FFF beams are advantageous for small field (e.g., SRS) treatments and are appropriate for intensity‐modulated radiotherapy (IMRT). For conventional 3D radiotherapy of large targets, FFF beams may be disadvantageous compared to flattened beams because of the heterogeneity of FFF beam across the target (unless modulation is employed). For any application, the nonflat beam characteristics and substantially higher dose rates require consideration during the commissioning and quality assurance processes relative to flattened beams, and the appropriate clinical use of the technology needs to be identified. Consideration also needs to be given to these unique characteristics when undertaking facility planning. Several areas still warrant further research and development. Recommendations pertinent to FFF technology, including acceptance testing, commissioning, quality assurance, radiation safety, and facility planning, are presented. Examples of clinical applications are provided. Several of the areas in which future research and development are needed are also indicated. PACS number: 87.53.‐j, 87.53.Bn, 87.53.Ly, 87.55.‐x, 87.55.N‐, 87.56.bc
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Affiliation(s)
- Ying Xiao
- Thomas Jefferson University Hospital.
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Younge KC, Wang Y, Thompson J, Giovinazzo J, Finlay M, Sankreacha R. Practical implementation of failure mode and effects analysis for safety and efficiency in stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 2015; 91:1003-8. [PMID: 25670543 DOI: 10.1016/j.ijrobp.2014.12.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/04/2014] [Accepted: 12/12/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To improve the safety and efficiency of a new stereotactic radiosurgery program with the application of failure mode and effects analysis (FMEA) performed by a multidisciplinary team of health care professionals. METHODS AND MATERIALS Representatives included physicists, therapists, dosimetrists, oncologists, and administrators. A detailed process tree was created from an initial high-level process tree to facilitate the identification of possible failure modes. Group members were asked to determine failure modes that they considered to be the highest risk before scoring failure modes. Risk priority numbers (RPNs) were determined by each group member individually and then averaged. RESULTS A total of 99 failure modes were identified. The 5 failure modes with an RPN above 150 were further analyzed to attempt to reduce these RPNs. Only 1 of the initial items that the group presumed to be high-risk (magnetic resonance imaging laterality reversed) was ranked in these top 5 items. New process controls were put in place to reduce the severity, occurrence, and detectability scores for all of the top 5 failure modes. CONCLUSIONS FMEA is a valuable team activity that can assist in the creation or restructuring of a quality assurance program with the aim of improved safety, quality, and efficiency. Performing the FMEA helped group members to see how they fit into the bigger picture of the program, and it served to reduce biases and preconceived notions about which elements of the program were the riskiest.
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Affiliation(s)
- Kelly Cooper Younge
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Yizhen Wang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - John Thompson
- Department of Radiation Oncology, Trillium Health Partners - Credit Valley Hospital Site, Mississauga Halton/Central West Regional Cancer Program, Mississauga, ON, Canada
| | - Julia Giovinazzo
- Department of Radiation Oncology, Trillium Health Partners - Credit Valley Hospital Site, Mississauga Halton/Central West Regional Cancer Program, Mississauga, ON, Canada
| | - Marisa Finlay
- Department of Radiation Oncology, Trillium Health Partners - Credit Valley Hospital Site, Mississauga Halton/Central West Regional Cancer Program, Mississauga, ON, Canada
| | - Raxa Sankreacha
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Ford EC, Smith K, Terezakis S, Croog V, Gollamudi S, Gage I, Keck J, DeWeese T, Sibley G. A streamlined failure mode and effects analysis. Med Phys 2015; 41:061709. [PMID: 24877804 DOI: 10.1118/1.4875687] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Explore the feasibility and impact of a streamlined failure mode and effects analysis (FMEA) using a structured process that is designed to minimize staff effort. METHODS FMEA for the external beam process was conducted at an affiliate radiation oncology center that treats approximately 60 patients per day. A structured FMEA process was developed which included clearly defined roles and goals for each phase. A core group of seven people was identified and a facilitator was chosen to lead the effort. Failure modes were identified and scored according to the FMEA formalism. A risk priority number,RPN, was calculated and used to rank failure modes. Failure modes with RPN > 150 received safety improvement interventions. Staff effort was carefully tracked throughout the project. RESULTS Fifty-two failure modes were identified, 22 collected during meetings, and 30 from take-home worksheets. The four top-ranked failure modes were: delay in film check, missing pacemaker protocol/consent, critical structures not contoured, and pregnant patient simulated without the team's knowledge of the pregnancy. These four failure modes had RPN > 150 and received safety interventions. The FMEA was completed in one month in four 1-h meetings. A total of 55 staff hours were required and, additionally, 20 h by the facilitator. CONCLUSIONS Streamlined FMEA provides a means of accomplishing a relatively large-scale analysis with modest effort. One potential value of FMEA is that it potentially provides a means of measuring the impact of quality improvement efforts through a reduction in risk scores. Future study of this possibility is needed.
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Affiliation(s)
- Eric C Ford
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Koren Smith
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Stephanie Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Victoria Croog
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Smitha Gollamudi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Irene Gage
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Jordie Keck
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Theodore DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
| | - Greg Sibley
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287
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Redesign of process map to increase efficiency: Reducing procedure time in cervical cancer brachytherapy. Brachytherapy 2015; 14:471-80. [PMID: 25572438 DOI: 10.1016/j.brachy.2014.11.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/13/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To increase intraprocedural efficiency in the use of clinical resources and to decrease planning time for cervical cancer brachytherapy treatments through redesign of the procedure's process map. METHODS AND MATERIALS A multidisciplinary team identified all tasks and associated resources involved in cervical cancer brachytherapy in our institution and arranged them in a process map. A redesign of the treatment planning component of the process map was conducted with the goal of minimizing planning time. Planning time was measured on 20 consecutive insertions, of which 10 were performed with standard procedures and 10 with the redesigned process map, and results were compared. Statistical significance (p < 0.05) was measured with a two-tailed t test. RESULTS Twelve tasks involved in cervical cancer brachytherapy treatments were identified. The process map showed that in standard procedures, the treatment planning tasks were performed sequentially. The process map was redesigned to specify that contouring and some planning tasks are performed concomitantly. Some quality assurance tasks were reorganized to minimize adverse effects of a possible error on procedure time. Test dry runs followed by live implementation confirmed the applicability of the new process map to clinical conditions. A 29% reduction in planning time (p < 0.01) was observed with the introduction of the redesigned process map. CONCLUSIONS A process map for cervical cancer brachytherapy was generated. The treatment planning component of the process map was redesigned, resulting in a 29% decrease in planning time and a streamlining of the quality assurance process.
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López-Tarjuelo J, Bouché-Babiloni A, Santos-Serra A, Morillo-Macías V, Calvo FA, Kubyshin Y, Ferrer-Albiach C. Failure mode and effect analysis oriented to risk-reduction interventions in intraoperative electron radiation therapy: the specific impact of patient transportation, automation, and treatment planning availability. Radiother Oncol 2014; 113:283-9. [PMID: 25465728 DOI: 10.1016/j.radonc.2014.11.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/05/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Industrial companies use failure mode and effect analysis (FMEA) to improve quality. Our objective was to describe an FMEA and subsequent interventions for an automated intraoperative electron radiotherapy (IOERT) procedure with computed tomography simulation, pre-planning, and a fixed conventional linear accelerator. MATERIAL AND METHODS A process map, an FMEA, and a fault tree analysis are reported. The equipment considered was the radiance treatment planning system (TPS), the Elekta Precise linac, and TN-502RDM-H metal-oxide-semiconductor-field-effect transistor in vivo dosimeters. Computerized order-entry and treatment-automation were also analyzed. RESULTS Fifty-seven potential modes and effects were identified and classified into 'treatment cancellation' and 'delivering an unintended dose'. They were graded from 'inconvenience' or 'suboptimal treatment' to 'total cancellation' or 'potentially wrong' or 'very wrong administered dose', although these latter effects were never experienced. Risk priority numbers (RPNs) ranged from 3 to 324 and totaled 4804. After interventions such as double checking, interlocking, automation, and structural changes the final total RPN was reduced to 1320. CONCLUSIONS FMEA is crucial for prioritizing risk-reduction interventions. In a semi-surgical procedure like IOERT double checking has the potential to reduce risk and improve quality. Interlocks and automation should also be implemented to increase the safety of the procedure.
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Affiliation(s)
- Juan López-Tarjuelo
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain.
| | - Ana Bouché-Babiloni
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Agustín Santos-Serra
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Virginia Morillo-Macías
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Felipe A Calvo
- Departamento de Oncología, Hospital General Universitario Gregorio Marañón Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Yuri Kubyshin
- Instituto de Técnicas Energéticas, Universidad Politécnica de Cataluña, Barcelona, Spain
| | - Carlos Ferrer-Albiach
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain; Facultad de Medicina, Universidad Cardenal Herrera-CEU, Castellón de la Plana, Spain
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Safety and feasibility of STAT RAD: Improvement of a novel rapid tomotherapy-based radiation therapy workflow by failure mode and effects analysis. Pract Radiat Oncol 2014; 5:106-12. [PMID: 25413416 DOI: 10.1016/j.prro.2014.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/12/2014] [Accepted: 03/31/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE The clinical challenge of radiation therapy (RT) for painful bone metastases requires clinicians to consider both treatment efficacy and patient prognosis when selecting a radiation therapy regimen. The traditional RT workflow requires several weeks for common palliative RT schedules of 30 Gy in 10 fractions or 20 Gy in 5 fractions. At our institution, we have created a new RT workflow termed "STAT RAD" that allows clinicians to perform computed tomographic (CT) simulation, planning, and highly conformal single fraction treatment delivery within 2 hours. In this study, we evaluate the safety and feasibility of the STAT RAD workflow. METHODS AND MATERIALS A failure mode and effects analysis (FMEA) was performed on the STAT RAD workflow, including development of a process map, identification of potential failure modes, description of the cause and effect, temporal occurrence, and team member involvement in each failure mode, and examination of existing safety controls. A risk probability number (RPN) was calculated for each failure mode. As necessary, workflow adjustments were then made to safeguard failure modes of significant RPN values. After workflow alterations, RPN numbers were again recomputed. RESULTS A total of 72 potential failure modes were identified in the pre-FMEA STAT RAD workflow, of which 22 met the RPN threshold for clinical significance. Workflow adjustments included the addition of a team member checklist, changing simulation from megavoltage CT to kilovoltage CT, alteration of patient-specific quality assurance testing, and allocating increased time for critical workflow steps. After these modifications, only 1 failure mode maintained RPN significance; patient motion after alignment or during treatment. CONCLUSIONS Performing the FMEA for the STAT RAD workflow before clinical implementation has significantly strengthened the safety and feasibility of STAT RAD. The FMEA proved a valuable evaluation tool, identifying potential problem areas so that we could create a safer workflow.
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Cure L, Zayas-Castro J, Fabri P. Challenges and opportunities in the analysis of risk in healthcare. ACTA ACUST UNITED AC 2014. [DOI: 10.1080/19488300.2014.911786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Masini L, Donis L, Loi G, Mones E, Molina E, Bolchini C, Krengli M. Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator. Pract Radiat Oncol 2014; 4:392-7. [PMID: 25407860 DOI: 10.1016/j.prro.2014.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/27/2014] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to analyze the application of the failure modes and effects analysis (FMEA) to intracranial stereotactic radiation surgery (SRS) by linear accelerator in order to identify the potential failure modes in the process tree and adopt appropriate safety measures to prevent adverse events (AEs) and near-misses, thus improving the process quality. METHODS AND MATERIALS A working group was set up to perform FMEA for intracranial SRS in the framework of a quality assurance program. FMEA was performed in 4 consecutive tasks: (1) creation of a visual map of the process; (2) identification of possible failure modes; (3) assignment of a risk probability number (RPN) to each failure mode based on tabulated scores of severity, frequency of occurrence and detectability; and (4) identification of preventive measures to minimize the risk of occurrence. RESULTS The whole SRS procedure was subdivided into 73 single steps; 116 total possible failure modes were identified and a score of severity, occurrence, and detectability was assigned to each. Based on these scores, RPN was calculated for each failure mode thus obtaining values from 1 to 180. In our analysis, 112/116 (96.6%) RPN values were <60, 2 (1.7%) between 60 and 125 (63, 70), and 2 (1.7%) >125 (135, 180). The 2 highest RPN scores were assigned to the risk of using the wrong collimator's size and incorrect coordinates on the laser target localizer frame. CONCLUSION Failure modes and effects analysis is a simple and practical proactive tool for systematic analysis of risks in radiation therapy. In our experience of SRS, FMEA led to the adoption of major changes in various steps of the SRS procedure.
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Affiliation(s)
- Laura Masini
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Laura Donis
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Gianfranco Loi
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Eleonora Mones
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Elisa Molina
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Cesare Bolchini
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Marco Krengli
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy; Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
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Severgnini M, de Denaro M, Bortul M, Vidali C, Beorchia A. In vivo dosimetry and shielding disk alignment verification by EBT3 GAFCHROMIC film in breast IOERT treatment. J Appl Clin Med Phys 2014; 16:5065. [PMID: 25679150 PMCID: PMC5689990 DOI: 10.1120/jacmp.v16i1.5065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/10/2014] [Accepted: 09/03/2014] [Indexed: 11/23/2022] Open
Abstract
Intraoperative electron radiation therapy (IOERT) cannot usually benefit, as conventional external radiotherapy, from software systems of treatment planning based on computed tomography and from common dose verify procedures. For this reason, in vivo film dosimetry (IVFD) proves to be an effective methodology to evaluate the actual radiation dose delivered to the target. A practical method for IVFD during breast IOERT was carried out to improve information on the dose actually delivered to the tumor target and on the alignment of the shielding disk with respect to the electron beam. Two EBT3 GAFCHROMIC films have been positioned on the two sides of the shielding disk in order to obtain the dose maps at the target and beyond the disk. Moreover the postprocessing analysis of the dose distribution measured on the films provides a quantitative estimate of the misalignment between the collimator and the disk. EBT3 radiochromic films have been demonstrated to be suitable dosimeters for IVD due to their linear dose-optical density response in a narrow range around the prescribed dose, as well as their capability to be fixed to the shielding disk without giving any distortion in the dose distribution. Off-line analysis of the radiochromic film allowed absolute dose measurements and this is indeed a very important verification of the correct exposure to the target organ, as well as an estimate of the dose to the healthy tissue underlying the shielding. These dose maps allow surgeons and radiation oncologists to take advantage of qualitative and quantitative feedback for setting more accurate treatment strategies and further optimized procedures. The proper alignment using elastic bands has improved the absolute dose accuracy and the collimator disk alignment by more than 50%.
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Affiliation(s)
- Mara Severgnini
- Department of Medical Physics, A.O.U. "Ospedali Riuniti" di Trieste, Italy.
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Broggi S, Cantone MC, Chiara A, Di Muzio N, Longobardi B, Mangili P, Veronese I. Application of failure mode and effects analysis (FMEA) to pretreatment phases in tomotherapy. J Appl Clin Med Phys 2013; 14:265-77. [PMID: 24036868 PMCID: PMC5714567 DOI: 10.1120/jacmp.v14i5.4329] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 04/04/2013] [Accepted: 03/19/2013] [Indexed: 11/23/2022] Open
Abstract
The aim of this paper was the application of the failure mode and effects analysis (FMEA) approach to assess the risks for patients undergoing radiotherapy treatments performed by means of a helical tomotherapy unit. FMEA was applied to the preplanning imaging, volume determination, and treatment planning stages of the tomotherapy process and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system; and 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. A total of 74 failure modes were identified: 38 in the stage of preplanning imaging and volume determination, and 36 in the stage of planning. The threshold of 125 for RPN was exceeded in four cases: one case only in the phase of preplanning imaging and volume determination, and three cases in the stage of planning. The most critical failures appeared related to (i) the wrong or missing definition and contouring of the overlapping regions, (ii) the wrong assignment of the overlap priority to each anatomical structure, (iii) the wrong choice of the computed tomography calibration curve for dose calculation, and (iv) the wrong (or not performed) choice of the number of fractions in the planning station. On the basis of these findings, in addition to the safety strategies already adopted in the clinical practice, novel solutions have been proposed for mitigating the risk of these failures and to increase patient safety.
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Failure modes and effects analysis applied to high-dose-rate brachytherapy treatment planning. Brachytherapy 2013; 12:382-6. [DOI: 10.1016/j.brachy.2013.03.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 03/13/2013] [Accepted: 03/14/2013] [Indexed: 11/27/2022]
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Cantone MC, Ciocca M, Dionisi F, Fossati P, Lorentini S, Krengli M, Molinelli S, Orecchia R, Schwarz M, Veronese I, Vitolo V. Application of failure mode and effects analysis to treatment planning in scanned proton beam radiotherapy. Radiat Oncol 2013; 8:127. [PMID: 23705626 PMCID: PMC3679803 DOI: 10.1186/1748-717x-8-127] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 05/19/2013] [Indexed: 11/21/2022] Open
Abstract
Background A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to the actively scanned proton beam radiotherapy process implemented at CNAO (Centro Nazionale di Adroterapia Oncologica), aiming at preventing accidental exposures to the patient. Methods FMEA was applied to the treatment planning stage and consisted of three steps: i) identification of the involved sub-processes; ii) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system, iii) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results Thirty-four sub-processes were identified, twenty-two of them were judged to be potentially prone to one or more failure modes. A total of forty-four failure modes were recognized, 52% of them characterized by an RPN score equal to 80 or higher. The threshold of 125 for RPN was exceeded in five cases only. The most critical sub-process appeared related to the delineation and correction of artefacts in planning CT data. Failures associated to that sub-process were inaccurate delineation of the artefacts and incorrect proton stopping power assignment to body regions. Other significant failure modes consisted of an outdated representation of the patient anatomy, an improper selection of beam direction and of the physical beam model or dose calculation grid. The main effects of these failures were represented by wrong dose distribution (i.e. deviating from the planned one) delivered to the patient. Additional strategies for risk mitigation, easily and immediately applicable, consisted of a systematic information collection about any known implanted prosthesis directly from each patient and enforcing a short interval time between CT scan and treatment start. Moreover, (i) the investigation of dedicated CT image reconstruction algorithms, (ii) further evaluation of treatment plan robustness and (iii) implementation of independent methods for dose calculation (such as Monte Carlo simulations) may represent novel solutions to increase patient safety. Conclusions FMEA is a useful tool for prospective evaluation of patient safety in proton beam radiotherapy. The application of this method to the treatment planning stage lead to identify strategies for risk mitigation in addition to the safety measures already adopted in clinical practice.
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Affiliation(s)
- Marie Claire Cantone
- Dipartimento di Fisica, Università degli Studi di Milano, Via Celoria 16, 20133, Milano, Italy
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