A streamlined failure mode and effects analysis. Issue 6 (14th May 2014)

• Record Type: Journal Article
• Authors: Ford, Eric C.; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg
• Is Part Of: Medical physics. Volume 41:Issue 6(2014)Part 1
• Page Start: n/a
• Page End: n/a
• Publication Date: 2014-05-14
• Subjects: Therapeutic applications, including brachytherapy; radiation therapy; patient safety -- failure mode and effects analysis (FMEA) -- radiation therapy; Radiation therapy; Cancer -- Failure analysis -- Databases -- Medical treatment planning -- Radiation treatment -- Medical radiation safety -- Structural failure; Medical physics -- Periodicals; Medical physics; Geneeskunde; Natuurkunde; Toepassingen; Biophysics; Periodicals; Periodicals; Electronic journals; 610.153
• DOI: 10.1118/1.4875687
• Languages: English
• ISSNs: 0094-2405

Abstract

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.