Modernization of safety environment for a dedicated beamline for proton ocular therapy

BACKGROUND

Proton therapy is an effective treatment for ocular melanoma, and other tumors of the eye. The fixed horizontal beamline dedicated to ocular treatments at Massachusetts General Hospital was originally commissioned in 2002, with much of the equipment, safety features, and practices dating back to an earlier implementation at Harvard Cyclotron in the 1970s.

PURPOSE

To describe the experience of reevaluation and enhancement of the safety environment for one of the longest continuously operating proton therapy programs.

METHODS

Several enhancements in quality control had been introduced throughout the years of operation, as described in this manuscript, to better align the practice with the evolving standards of proton therapy and the demands of a modern hospital. We spotlight the design and results of the failure mode and effect analysis (FMEA), and subsequent actions introduced to mitigate the modes associated with elevated risk. The findings of the FMEA informed the specifications for the new software application, which facilitated the improved management of the treatment workflow and the image-guidance aspects of ocular treatments.

RESULTS

Eleven failure modes identified as having the highest risk are described. Six of these were mitigated with the clinical roll-out of a new application for image-guided radiation therapy (IGRT). Others were addressed through task automation, the broader introduction of checklists, and enhancements in pre-treatment staff-led time-out.

CONCLUSIONS

Throughout the task of modernizing the safety system of our dedicated ocular beamline, FMEA proved to be an effective instrument in soliciting inputs from the staff about safety and workflow concerns, helping to identify steps associated with elevated failure risks. Risks were reduced with the clinical introduction of a new IGRT application, which integrates quality management tools widely recognized for their role in risk mitigation: automation of the data transfer and workflow steps, and with the introduction of checklists and redundancy cross-checks.

Optimization of the emergency endoscopy process for patients with esophagogastric variceal bleeding using failure mode and effect analysis

OBJECTIVE

To optimize the emergency endoscopy process for patients with esophagogastric variceal bleeding (EGVB) using failure mode and effect analysis (FMEA).

METHOD

In this retrospective analysis, we enrolled patients who were hospitalized in Ganzhou People's Hospital from January 2021 to December 2021. They were divided into 51 cases before and 51 cases after the intervention according to the time of FMEA model intervention. The risk of unsafe transport, endoscopic hemostasis success rate, RPN (risk priority number) value, dual venous access time, resuscitation success rate, emergency endoscopy timeout execution rate, patient health education awareness rate, and endoscopic ligation of esophageal varices (EVL) procedure volume were compared accordingly before and after the procedure.

RESULTS

After the FMEA intervention, the emergency endoscopy process for EGVB patients was optimized, the risk of unsafe transport for emergency EGVB endoscopy was reduced, and the success rate of emergency endoscopic hemostasis for patients was improved. Also, the failure mode of RPN values greater than 12 was improved. After the countermeasures were implemented, the resuscitation success rate of EGVB patients reached 95%, the safe transport pass rate increased from 88% to 98.7%, and the patient health education awareness increased from 69% to 92%. The number of EGVB patients who underwent EVL surgery ranked second in the province. The waiting time, gastric function recovery time, dual venous access time, and hospital stay of patients who underwent the optimized procedure were significantly shorter compared to those before implementation (all P<0.01). The incidence of adverse events was significantly lower in patients who underwent the optimized procedure compared to the pre-implementation period (P<0.01).

CONCLUSION

Applying FMEA to analyze and optimize the process of EGVB patients undergoing emergency endoscopy can maximize patient life safety and treatment safety, as well as improve medical quality and care safety.

Semi-Quantitative Risk Assessment of African Swine Fever Virus Introduction in Outdoor Pig Farms

In a previous study, a semi-quantitative risk assessment was developed to rank pig holdings in terms of likelihood of introducing African swine fever virus (ASFV) by assessing their compliance with biosecurity and exposure to geographical risk factors. The method was initially developed for confined pig holdings, but given that ASF is endemic in wild boar of several countries, we modified the approach to make it suitable for free-range farms as well. In the current study, a total of 41 outdoor pig farms were assessed in an area where exposure to wild boar was generally high (density from 2.3 to 10.3 wild boar per Km²). As expected, non-compliance with biosecurity measures was frequent in outdoor farms, and the frequency of non-compliance indicated that the absence of adequate separation of pigs from the external environment was the major weakness in the farms assessed. In 46.3% of them, there was no fence or, if present, it was not adequate to avoid contact with wild boar. However, the approach adopted proved to be suitable for identifying intervention priorities to mitigate the risk of ASFV spread in free-range pig herds and for identifying the weaknesses of individual farms, as recommended by EFSA in 2021, which suggests implementing tools to improve biosecurity by favoring higher-risk farms.

Determining the quality control frequency of an MR-linac using risk matrix (RM) analysis

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.

Semi-quantitative risk assessment of African swine fever virus introduction in pig farms

A semi-quantitative risk assessment was developed to classify pig farms in terms of the probability of introduction of African swine fever virus (ASFV). Following on-farm data collection via a specific checklist, we applied a modified failure mode and effect analysis (FMEA) to calculate the risk priority codes (RPC's), indicating increasing risk levels ranging from 1 to 5. The importance of biosecurity measures was attributed by experts. To consider geographic risk factors, we classified pig farms based on local density of farmed pigs, and on the estimated wild boar population density. The combination of RPC's with geographical risk factors resulted into a final ranking of pig farms in terms of the risk of ASFV introduction. Furthermore, the estimation of frequency and levels of non-compliance with biosecurity measures was used to identify weak points in risk prevention at farm level. The outcome of the risk assessment was affected by choices in assigning non-compliance scores and importance to specific components of biosecurity. The method was applied in 60 commercial farms in major pig production areas in Italy. Furthermore, we applied a reduced version of our checklist in 12 non-commercial/small commercial (≤20 pigs) farms in the northern Apennines. In commercial farms, highest RPC's were obtained for biosecurity measures associated with personnel practices and farm buildings/planimetry. Intervention should be addressed to training of personnel on biosecurity and ASF, to avoid contacts with other pig herds, and to improve practices in the entrance into the farm. Sharing trucks with other farms, and loading/unloading of pigs were other weak points. Fencing was classified as insufficient in 70% of the commercial farms. Among these farms, breeding units were characterised by the lowest risk of ASFV introduction (although differences among median ranks were not statistically significant: P-value = 0.07; Kruskal-Wallis test), and increasing herd size was not significantly correlated with a higher risk (Kendall's τ = -0.13; P-value = 0.14). Density of farmed pig was greatest in the main pig production area in northern Italy. Conversely, exposure to wild boars was greatest for non-commercial/small commercial farms on the Apennines, which were also characterised by non-compliance with critical biosecurity measures.

Occupational Safety Analysis for COVID-Instigated Repurposed Manufacturing Lines: Use of Nanomaterials in Injection Moulding

The COVID-19 pandemic instigated massive production of critical medical supplies and personal protective equipment. Injection moulding (IM) is considered the most prominent thermoplastic part manufacturing technique, offering the use of a large variety of feedstocks and rapid production capacity. Within the context of the European Commission-funded imPURE project, the benefits of IM have been exploited in repurposed IM lines to accommodate the use of nanocomposites and introduce the unique properties of nanomaterials. However, these amendments in the manufacturing lines highlighted the need for targeted and thorough occupational risk analysis due to the potential exposure of workers to airborne nanomaterials and fumes, as well as the introduction of additional occupational hazards. In this work, a safety-oriented failure mode and effects analysis (FMEA) was implemented to evaluate the main hazards in repurposed IM lines using acrylonitrile butadiene styrene (ABS) matrix and silver nanoparticles (AgNPs) as additives. Twenty-eight failure modes were identified, with the upper quartile including the seven failure modes presenting the highest risk priority numbers (RPN), signifying a need for immediate control action. Additionally, a nanosafety control-banding tool allowed hazard classification and the identification of control actions required for mitigation of occupation risks due to the released airborne silver nanoparticles.

Comparison between tube test and automated column agglutination technology on VISION Max for anti-A/B isoagglutinin titres: A multidimensional analysis

BACKGROUND AND OBJECTIVES

VISION Max (Ortho Clinical Diagnostics, Raritan, NJ) measures anti-A/B isoagglutinin titres using automated column agglutination technology (CAT). We compared tube test (TT) and CAT of VISION Max comprehensively, including failure mode and effect analysis (FMEA), turnaround time (TAT) and cost, and suggested modified CAT (MCAT).

MATERIALS AND METHODS

For 100 samples (each 25 for blood type A, B and O with anti-A and anti-B), anti-A/B isoagglutinin titres were measured by TT and CAT (1:2-1:1024 dilution), as well as by MCAT (with agglutination at 1:32 dilution, then perform additional testing from 1:64 to 1:1024). We assessed the agreement and correlation between TT and CAT and compared FMEA (risk priority number [RPN] score), TAT (h:min:sec) and cost (US dollar, US $) among TT, CAT and MCAT.

RESULTS

TT and CAT showed overall substantial agreement (k = 0.73) and high correlation (ρ ≥ 0.75) except blood type O with anti-A (ρ = 0.68). Compared with TT, CAT showed lower RPN scores in FMEA and similar TAT and cost (FMEA, 33,700 vs. 184,300; TAT, 15:23:00 vs. 14:26:40; cost, 1377.4 vs. 1312.4, respectively). Regarding FMEA, TAT and cost, MCAT was superior to CAT or TT (43,810; 13:28:00; 899.2, respectively).

CONCLUSION

This is the first multidimensional analysis on VISION Max CAT for measuring anti-A/B isoagglutinin titres. The results of anti-A/B isoagglutinin titres by CAT were comparable with those of TT. MCAT would be a safe, time-saving and cost-effective alternative to TT and CAT in high-volume blood bank laboratories.

[Research on Bayesian fault diagnosis model of traditional Chinese medicine dry granulation based on failure model and effect analysis (FMEA)]

This paper aims to construct a Bayesian(BN) fault diagnosis model of traditional Chinese medicine dry granulation based on the failure model and effect analysis(FMEA), effectively control risk factors and ensure the quality of granules.Firstly, the risk ana-lysis of dry granulation process was carried out with FMEA, and the selected medium and high risk factors were taken as node variables to establish corresponding BN network with causality.According to the mathematical reasoning method of probability theory, the model was accurately inferred and verified by Netica, and the granule nonconformance was used as the evidence for reversed reasoning to determine the most likely cause of the failure that affected the granule quality.The BN fault diagnosis model of traditional Chinese medicine dry gra-nulation was established based on the medium and high risk factors of process, prescription and equipment screened out by FMEA, such as roller pressure, raw material viscosity, clearance between rollers in the paper.The fault diagnosis of traditional Chinese medicine dry granulation process was then carried out according to the model, and the posterior probability of each node under the premise of nonconforming granule quality was obtained.This method could provide strong support for operators to quickly eliminate faults and make decisions, so as to improve the efficiency and accuracy for fault diagnosis and prediction, with innovation in its application.

Evaluating Surgical Risk Using FMEA and MULTIMOORA Methods under a Single-Valued Trapezoidal Neutrosophic Environment

Background

Human errors during operations may seriously threaten patient recovery and safety and affect the doctor–patient relationship. Therefore, risk evaluation of the surgical process is critical. Risk evaluation by failure mode and effect analysis (FMEA) is a prospective technology that can identify and evaluate potential failure modes in the surgical process to ensure surgical quality and patient safety. In this study, a hybrid surgical risk–evaluation model was proposed using FMEA and multiobjective optimization on the basis of ratio analysis plus full multiplicative form (MULTIMOORA) method under a single-valued trapezoidal neutrosophic environment. This work aimed to determine the most critical risk points during the surgical process and analyze corresponding solutions.

Methods

A team for FMEA was established from domain experts from different departments in a hospital in Hunan Province. Single-valued trapezoidal neutrosophic numbers (SVTNNs) were used to evaluate potential risk factors in the surgical process. Cmprehensive weights combining subjective and objective weights were determined by the best–worst method and entropy method to differentiate the importance of risk factors. The SVTNN–MULTIMOORA method was utilized to calculate the risk-priority order of failure modes in a surgical process.

Results

The hybrid FMEA model under the SVTNN–MULTIMOORA method was used to calculate the ranking of severity of 21 failure modes in the surgical process. An unclear diagnosis is the most critical failure in the surgical process of a hospital in Hunan Province.

Conclusion

The proposed model can identify and evaluate the most critical potential failure modes of the surgical process effectively. In addition, such a model can help hospitals to reduce surgical risk and improve the safety of surgery.

An Extension of the Failure Mode and Effect Analysis with Hesitant Fuzzy Sets to Assess the Occupational Hazards in the Construction Industry

The construction industry is considered as one of the most dangerous industries in terms of occupational safety and has a high rate of occupational incidents and risks compared to other industries. Given the importance of identifying and assessing the occupational hazards in this industry, researchers have conducted numerous studies using statistical methods, multi-criteria decision-making methods, expert-based judgments, and so on. Although, these researchers have used linguistic variables, fuzzy sets and interval-valued intuitionistic fuzzy sets to overcome challenges such as uncertainty and ambiguity in the risk assessment conducted by experts; the previous models lack in efficiency if the experts are hesitant in their assessment. This leads to the inability to assign a specific membership degree to any risk. Therefore, in this research, it is tried to provide an improved approach to the Failure Mode and Effects Analysis (FMEA) method using an Multi-Criteria Decision-Making (MCDM) method based on the hesitant fuzzy set, which can effectively cope with the hesitance of the experts in the evaluation. Also, Stepwise Weight Assessment Ratio Analysis (SWARA) method is applied for risk factor weighing in the proposed approach. This model is applied to a construction industry case study to solve a realistic occupational risk assessment. Moreover, a comparison is made between the results of this model and those obtained by the conventional FMEA and some other aggregation operators. The results indicate that the newly developed approach is useful and flexible to address complex FMEA problems and can generate logical and reliable priority rankings for failure modes.

Failure mode and effects analysis of linac-based liver stereotactic body radiotherapy

PURPOSE

Although stereotactic body radiation therapy (SBRT) is an attractive noninvasive approach for liver irradiation, it presents specific challenges associated with respiration-induced liver motion, daily tumor localization due to liver deformation, and poor visualization of target with respect to adjacent normal liver in computed tomography (CT). We aim to identify potential hazards and develop a set of mitigation strategies to improve the safety of our liver SBRT program, using failure mode and effect analysis (FMEA).

MATERIALS AND METHODS

A multidisciplinary group consisting of two physicians, three physicists, two dosimetrists, and two therapists was formed. A process map covering ten major stages of the liver SBRT program from the initial diagnosis to posttreatment follow-up was generated. A total of 102 failure modes (FM), together with their causes and effects, were identified. The occurrence (O), severity (S), and lack of detectability (D) were independently scored using a scale from 1 (lowest risk) to 10 (largest risk). The ranking was done using the risk probability number (RPN) defined as the product of average O, S, and D numbers for each mode. Two fault tree analyses were performed. The failure modes with the highest RPN values as well as highest severity score were considered for investigation and a set of mitigation strategies was developed to address these.

RESULTS

The median RPN (RPN_med ) values for all modes ranged from of 9 to 105 and the highest median S score (S_med ) was 8. Fourteen FMs were identified to be significant by both RPN_med and S_med (top ten RPN_med ranked and highest S_med FMs) and 12 of them were considered for risk mitigation efforts. The remaining two were omitted due to either sufficient checks already in place, or lack of practical mitigation strategies. Implemented measures consisted of five physics tasks, two physician tasks, and three workflow changes.

CONCLUSIONS

The application of FMEA to our liver SBRT program led to the identification of potential FMs and allowed improvement measures to enhance the safety of our clinical practice.

[Risk Analysis of Radiotherapy Implementation Process Based on Failure Mode and Effect Analysis]

OBJECTIVE

Providing a risk assessment method for the implementation of radiotherapy to identify possible risks in the implementation of the treatment process, and proposing measures to reduce or prevent these risks.

METHODS

A multidisciplinary expert evaluation team was developed and the radiotherapy treatment process flow was drawn. Through the expert team, the failure mode analysis is carried out in each step of the flow chart. The results were summarized and the RPN (risk priority ordinal) score was obtained, and the quantitative evaluation results of the whole process risk were obtained.

RESULTS

One hundred and six failure modes were obtained, risk assessment of RPN (20%) high risk failure model are 22 and severity S (≥ 8) high risk failure model are 27. The reasons for the failures were man-made errors or hardware and software failures.

CONCLUSIONS

Failure mode and effect analysis can be used to evaluate the risk assessment of radiotherapy, and it provides a new solution for risk control in radiotherapy field.

Comprehensive protocol of traceability during IVF: the result of a multicentre failure mode and effect analysis

STUDY QUESTION

Can traceability of gametes and embryos be ensured during IVF?

SUMMARY ANSWER

The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches.

WHAT IS KNOWN ALREADY

Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed.

STUDY DESIGN, SIZE, DURATION

Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In each centre, this study involved: the laboratory director, the Quality Control & Quality Assurance responsible, Embryologist(s), Gynaecologist(s), Nurse(s) and Administration. The FMEA analyses were performed according to the Joint Commission International.

MAIN RESULTS AND THE ROLE OF CHANCE

The FMEA teams identified seven main process phases: oocyte collection, sperm collection, gamete processing, insemination, embryo culture, embryo transfer and gamete/embryo cryopreservation. A mean of 19.3 (SD ± 5.8) associated process steps and 41.9 (SD ± 12.4) possible failure modes were recognized per centre. A RPN ≥15 was calculated in a mean of 6.4 steps (range 2-12, SD ± 3.60). A total of 293 failure modes were centrally analysed 45 of which were considered at medium/high risk. After consistent corrective measures implementation and re-evaluation, a significant reduction in the RPNs in all centres (RPN <15 for all steps) was observed. A simple and comprehensive traceability system was designed as the result of the seven FMEA analyses.

LIMITATIONS, REASONS FOR CAUTION

The validity of FMEA is in general questionable due to the subjectivity of the judgments. The design of this study has however minimized this risk by introducing external experts for the analysis of the FMEA results. Specific situations such as sperm/oocyte donation, import/export and pre-implantation genetic testing were not taken into consideration. Finally, this study is only limited to the analysis of failure modes that may lead to mismatches, other possible procedural mistakes are not accounted for.

WIDER IMPLICATIONS OF THE FINDINGS

Every single IVF centre should have a clear and reliable protocol for identification of patients and traceability of cells during manipulation. The results of this study can support IVF groups in better recognizing critical steps in their protocols, understanding identification and witnessing process, and in turn enhancing safety by introducing validated corrective measures.

STUDY FUNDING/COMPETING INTEREST(S)

This study was designed by the Italian Society of Embryology Reproduction and Research (SIERR) and funded by the Italian National Transplant Centre (CNT) of the Italian National Institute of Health (ISS). The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Quality by Design Empowered Development and Optimisation of Time-Controlled Pulsatile Release Platform Formulation Employing Compression Coating Technology

The research was envisaged for development of time-controlled pulsatile release (PR) platform formulation to facilitate management of early morning chronological attacks. The development was started using prednisone as a model drug wherein core tablets were prepared using direct compression method and subsequently compression-coated with ethylcellulose (EC)-hydroxypropyl methylcellulose (HPMC) excipient blend. Initially, quality target product profile was established and risk assessment was performed using failure mode and effect analysis. In an endeavour to accomplish the objective, central composite design was employed as a design of experiment (DoE) tool. Optimised compression-coated tablet (CCT) exhibited 4-6 h lag time followed by burst release profile under variegated dissolution conditions viz. multi-media, change in apparatus/agitation and biorelevant media. Afterwards, five different drugs, i.e. methylprednisolone, diclofenac sodium, diltiazem hydrochloride, nifedipine and lornoxicam, were one-by-one incorporated into the optimised prednisone formula with replacement of former drug. Change in drug precipitated the issues like poor solubility and flow property which were respectively resolved through formulation of solid dispersion and preparation of active pharmaceutical ingredient (API) granules. Albeit, all drug CCTs exhibited desired release profile similar to prednisone CCTs. In nutshell, tour de force of research epitomised the objective of incorporating diverse drug molecules and penultimately obtaining robust release profile at varying dissolution conditions.

Clinical risk assessment in intensive care unit

BACKGROUND

Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin's Social Security Hospital (Razi Hospital) through Failure Mode and Effect Analysis (FMEA).

METHODS

This was a qualitative-quantitative research by Focus Discussion Group (FDG) performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique.

RESULTS

Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN) was in respiratory care "Ventilator's alarm malfunction (no alarm)" with the score 288, and the lowest was in gastrointestinal "not washing the NG-Tube" with the score 8.

CONCLUSIONS

Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care.