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  5. A Failure Modes and Effects Analysis Identified Poor Communication as the Greatest Weakness in the Process of Patient Specific IMRT QA

A Failure Modes and Effects Analysis Identified Poor Communication as the Greatest Weakness in the Process of Patient Specific IMRT QA

K Verdecchia*, T Cui, S Kost, M Sands, L Zickefoose, T Kovacs, A Godley, Cleveland Clinic, Cleveland, OH

Presentations

(Tuesday, 7/31/2018) 9:30 AM - 10:00 AM

Room: Exhibit Hall | Forum 7

Purpose: Accurate delivery of a radiation treatment course depends on many factors. The overall process of IMRT planning involves multiple stages requiring efforts from an entire radiation oncology team, of which pre-treatment delivery confirmation (IMRT QA) is vital. This study implemented a failure modes and effects analysis (FMEA) highlighted by TG-100 to identify workflow weaknesses for patient specific IMRT QA.

Methods: A multidisciplinary team was created with a physicist, physics residents, a therapist, and a dosimetrist to analyze our process of IMRT QA. First, potential failure modes, causes of failure, and current design controls were identified for various IMRT QA items, such as notification to perform IMRT QA, planar dose generation, and IMRT QA analysis. The severity, probability of occurrence, and detection for each item were ranked to compute the risk priority number (RPN); weaknesses were identified by RPN values > 200 and a fault tree was generated.

Results: A total of 41 failure modes were recognized. The most severe outcome of a failure in the IMRT QA process was defined as treating a patient without prior correct performance of IMRT QA. Non-performance of IMRT QA occurs most frequently for adaptive replans, accidental completion of the quality checklist item, or changes to a treatment technique (3D to IMRT) during planning. As a result, the addition of a new IMRT QA quality checklist item has been added to the record and verify software (MOSAIQ), which forewarns the physics staff of an upcoming IMRT replan. Additionally, the previous flag used by therapists, “IMRT QA Complete�, has been renamed to reduce accidental completion of a quality checklist item, “IMRT QA�.

Conclusion: An FMEA identified poor communication as the greatest potential cause of treating a patient without prior completion of IMRT QA. Changes in the IMRT QA workflow have been implemented to optimize communication.

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