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Assessment of Approach and Evaluation for Performing Failure-Mode and Effects Analysis for Brachytherapy

S Roles*, G Cardarelli , M Schwer , E Klein , T Roth , J Brindle , M Rivard , Rhode Island Hospital / Warren Alpert Medical, Providence, RI


(Sunday, 7/14/2019) 4:00 PM - 5:00 PM

Room: 301

Purpose: Renovation of the brachytherapy program at a leading cancer center utilized methods of the AAPM TG-100 report to objectively evaluate current clinical workflows and develop techniques for minimizing failure modes, increasing efficiency, and consequently improving overall treatment quality. The TG-100 report guides evaluation of clinical workflows with recommendations for identifying potential failure modes and scoring such failure modes from the perspective of their occurrence frequency, failure severity, and the inability to detect them. The current study assessed the impact of differing methods to determine the risk priority number (RPN) beyond simply multiplying O, S, and D.

Methods: The clinical workflow for a complex brachytherapy procedure was evaluated by a team of 15 staff members and identified 51 discrete failure modes. Alternative to the TG-100 report, the scales used for determining O, S, and D values were expanded over all clinically-relevant possibilities with care to emphasize mitigation of natural bias for scoring near the median range as well as to enhance the overall granularity of such scales.

Results: Areas for improved scale-granularity were highlighted following delineation of our scoring methods, which diminished potential for failure-mode scoring bias and ambiguity. O and D provide quantitative measures; however, the S metric is subjective which effectively decreases accuracy of the comparison. With application to the brachytherapy procedure, the majority of failure modes resulted in metrics inadequately resolved using the TG-100 scoring system through the multiplication of O, S, and D. As RPN results are relative values, discernment of various possibilities is important. Based on the staff members’ perceptions, a more realistic measure of risk was determined using weighted-functions of O, S, and D rather than simply multiplying them together.

Conclusion: Detailed methods from the TG-100 approach were questioned towards deriving a more realistic risk assessment for a complex brachytherapy procedure.


Not Applicable / None Entered.


TH- Brachytherapy: General (most aspects)

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