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Wegener S, Käthner P, Weick S, Schindhelm R, Breuer K, Stark S, Hutzel H, Lutyj P, Zimmermann M, Tamihardja J, Wittig A, Exner F, Razinskas G. Re-evaluation of the prospective risk analysis for artificial-intelligence driven cone beam computed tomography-based online adaptive radiotherapy after one year of clinical experience. Z Med Phys 2024; 34:397-407. [PMID: 38852003 DOI: 10.1016/j.zemedi.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/01/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
Cone-beam computed tomography (CBCT)-based online adaptation is increasingly being introduced into many clinics. Upon implementation of a new treatment technique, a prospective risk analysis is required and enhances workflow safety. We conducted a risk analysis using Failure Mode and Effects Analysis (FMEA) upon the introduction of an online adaptive treatment programme (Wegener et al., Z Med Phys. 2022). A prospective risk analysis, lacking in-depth clinical experience with a treatment modality or treatment machine, relies on imagination and estimates of the occurrence of different failure modes. Therefore, we systematically documented all irregularities during the first year of online adaptation, namely all cases in which quality assurance detected undesired states potentially leading to negative consequences. Additionally, the quality of automatic contouring was evaluated. Based on those quantitative data, the risk analysis was updated by an interprofessional team. Furthermore, a hypothetical radiation therapist-only workflow during adaptive sessions was included in the prospective analysis, as opposed to the involvement of an interprofessional team performing each adaptive treatment. A total of 126 irregularities were recorded during the first year. During that time period, many of the previously anticipated failure modes (almost) occurred, indicating that the initial prospective risk analysis captured relevant failure modes. However, some scenarios were not anticipated, emphasizing the limits of a prospective risk analysis. This underscores the need for regular updates to the risk analysis. The most critical failure modes are presented together with possible mitigation strategies. It was further noted that almost half of the reported irregularities applied to the non-adaptive treatments on this treatment machine, primarily due to a manual plan import step implemented in the institution's workflow.
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Affiliation(s)
- Sonja Wegener
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Paul Käthner
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Stefan Weick
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Robert Schindhelm
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Kathrin Breuer
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Silke Stark
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Heike Hutzel
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Paul Lutyj
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Marcus Zimmermann
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Jörg Tamihardja
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Andrea Wittig
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Florian Exner
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Gary Razinskas
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
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Parsons D, Lim TY, Teruel JR, Galavis P, Agostinelli S, Liang J, Mancosu P, Cherpak A, Stanley DN, Ahn KH, Guo B, Gonzalez Y, Burmeister J, Wong JY, Gu X, Kim GGY. Considerations for intensity modulated total body or total marrow and lymphoid irradiation. Clin Transl Radiat Oncol 2023; 43:100674. [PMID: 37753462 PMCID: PMC10518336 DOI: 10.1016/j.ctro.2023.100674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
We compiled a sampling of the treatment techniques of intensity-modulated total body irradiation, total marrow irradiation and total marrow and lymphoid irradiation utilized by several centers across North America and Europe. This manuscript does not serve as a consensus guideline, but rather is meant to serve as a convenient reference for centers that are considering starting an intensity-modulated program.
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Affiliation(s)
- David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tze Yee Lim
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose R. Teruel
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | - Paulina Galavis
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | | | - Jieming Liang
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Pietro Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Rozzano, Milan, Italy
| | - Amanda Cherpak
- Department of Radiation Oncology and Department of Medical Physics, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kang-Hyun Ahn
- Department of Radiation Oncology, University of Illinois, Chicago, IL and Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Bingqi Guo
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Yesenia Gonzalez
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Center, Detroit, MI, USA
| | - Jeffrey Y.C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Xuejun Gu
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Grace Gwe-Ya Kim
- Radiation Medicine and Applied Science, University of California San Diego, La Jolla, CA, USA
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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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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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