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Implementation of failure mode and effective analysis for high dose rate brachytherapy at Tata Memorial Hospital, Mumbai, India.

In Cancer Radiothérapie
By: Swamidas J [Corresponding author].
Contributor(s): Khanna N | Mahantshetty U | Somesan V | Deshpande DD | Shrivastava SK.
Material type: materialTypeLabelArticlePublisher: 2018Description: .Subject(s): Analyse des modes de défaillance | Brachytherapy | Curiethérapie | Failure mode and effective analysis | Haut débit de dose | High dose rate | Patient safety | Sécurité In: Cancer Radiothérapie Vol. 22, no. 4, p. 334-340Summary: Abstract PURPOSE: To report our experience of failure mode and effective analysis for high dose rate brachytherapy of gynaecological cancer carried out in our hospital. MATERIALS AND METHODS: Failure mode and effective analysis process described in AAPM TG 100 was followed: a multidisciplinary team consisting of two physicians, physicists, dosimetrists, a medical resident, a nurse, and a secretary was formed. A weekly meeting was held for four months. A process tree was created based on the overview of the entire process, with the main branches as follows: procedure in the operating room, patient imaging, contouring, treatment planning, machine quality assurance and treatment delivery. Each team member assigned the risk probability numbers based on the predefined scoring system. For a particular failure mode, if the risk probability number assigned by one member differed from the other, the highest risk probability number was taken into consideration. RESULTS: The process tree consisted of 185 nodes, with risk probability numbers ranging from 1-220, with 77 possible failure modes. Four nodes were found with risk probability numbers greater than 200, which were considered for immediate process improvements. Twenty-four nodes were found to be with risk probability numbers ranging from 100 to 200. All 24 processes were considered for process improvement, out of which 12 were found effective and feasible, which includes failure nodes with high severity score at least 8. The processes with high-risk probability numbers (greater than 200) were reduced after the introduction of process improvements. For the other processes, standard procedures were modified. The common causes of failure, were found to be due to lack of attention, human error and work pressure. CONCLUSIONS: Failure mode and effective analysis is a useful tool that uses a systematic approach for quality management of a specific process.
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Address for correspondence: svjamema@gmail.com.

Abstract
PURPOSE:
To report our experience of failure mode and effective analysis for high dose rate brachytherapy of gynaecological cancer carried out in our hospital.

MATERIALS AND METHODS:
Failure mode and effective analysis process described in AAPM TG 100 was followed: a multidisciplinary team consisting of two physicians, physicists, dosimetrists, a medical resident, a nurse, and a secretary was formed. A weekly meeting was held for four months. A process tree was created based on the overview of the entire process, with the main branches as follows: procedure in the operating room, patient imaging, contouring, treatment planning, machine quality assurance and treatment delivery. Each team member assigned the risk probability numbers based on the predefined scoring system. For a particular failure mode, if the risk probability number assigned by one member differed from the other, the highest risk probability number was taken into consideration.

RESULTS:
The process tree consisted of 185 nodes, with risk probability numbers ranging from 1-220, with 77 possible failure modes. Four nodes were found with risk probability numbers greater than 200, which were considered for immediate process improvements. Twenty-four nodes were found to be with risk probability numbers ranging from 100 to 200. All 24 processes were considered for process improvement, out of which 12 were found effective and feasible, which includes failure nodes with high severity score at least 8. The processes with high-risk probability numbers (greater than 200) were reduced after the introduction of process improvements. For the other processes, standard procedures were modified. The common causes of failure, were found to be due to lack of attention, human error and work pressure.

CONCLUSIONS:
Failure mode and effective analysis is a useful tool that uses a systematic approach for quality management of a specific process.

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