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Failure Mode and Effects Analysis of High Dose Rate Brachytherapy to Improve Patient Safety

A Saini*, D Hunt , D Opp , S Wasserman , Moffitt Cancer Center, Tampa, FL


(Sunday, 7/29/2018) 3:00 PM - 6:00 PM

Room: Exhibit Hall

Purpose: Failure Mode and Effects Analysis (FMEA) is widely used to evaluate patient safety in radiation therapy. However, reports about FMEA for high dose rate (HDR) brachytherapy are limited. The purpose of this study was to apply the FMEA to HDR brachytherapy to improve patient safety at our center.

Methods: The authors performed a FMEA of our high dose rate brachytherapy program. The authors outlined the process for patients undergoing high dose rate brachytherapy procedures. Processes for source calibration, patient consultation, simulation, contouring, treatment planning, and treatment delivery were analyzed to identify failure modes. Following TG-100, we estimated the frequency of occurrence (O), the likelihood of being undetected (D), and the severity of the error in case it went undetected (S) and from these values, the risk priority number (RPN) was calculated. RPN scores were used to identify the highest risk points of the procedure for consideration of possible process changes to mitigate the risk.

Results: The authors identified a total of 66 possible failure modes associated with HDR brachytherapy and calculated their RPN values. From the combined list, our top three failure modes were: assigning the tip position to a catheter, reconstruction of catheters, and channel mapping. It was proposed that visual inspection of a screen showing the catheter reconstruction could mitigate the risk of error for these steps. The FMEA was completed over about one month period.

Conclusion: The FMEA technique provides a systematic approach to identify possible errors in high dose rate brachytherapy with modest staff effort. Based on the FMEA, a facility can design their quality improvement criteria and streamline their HDR brachytherapy program.  


Not Applicable / None Entered.


TH- Brachytherapy: General (most aspects)

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