@article{8183, author = {Eric Ford and Ray Gaudette and Lee Myers and Bruce Vanderver and Lilly Engineer and Richard Zellars and Danny Y. Song and John Wong and Theodore L. Deweese}, title = {Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.}, abstract = {

PURPOSE: Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology.

METHODS AND MATERIALS: We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode.

RESULTS: Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process.

CONCLUSIONS: The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard.

}, year = {2009}, journal = {Int J Radiat Oncol Biol Phys}, volume = {74}, pages = {852-8}, month = {07/2009}, issn = {1879-355X}, doi = {10.1016/j.ijrobp.2008.10.038}, language = {eng}, }