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Utilization of Failure Mode Effect Analysis (FMEA) to Generate An Initial Plan Check Checklist

P Rassiah-Szegedi*, F Su , Y Huang , D Spitznagel , V Sarkar , M Szegedi , H Zhao , A Paxton , G Nelson , B Salter , University Utah, Salt Lake City, UT


(Thursday, 7/18/2019) 1:00 PM - 3:00 PM

Room: 304

Purpose: To apply Failure Mode and Effect Analysis (FMEA) to generate an effective and efficient initial physics plan check list.

Methods: AA team of physicists, dosimetrists and therapists was set up to reconstruct the workflow processes involved in generation of a treatment plan beginning from simulation. The team then identified possible failure modes in each of the processes. For each error, the severity, frequency of occurrence and the probability of detection was assigned a value and the risk priority number (RPN) was calculated. The values assigned were based on TG 100. Prior to assigning a value, the team discussed the values in the scoring system to reduce the randomness in scoring. A local database of errors was used to help guide the scoring of frequency and severity.

Results: 67 possible failure modes were identified starting from simulation to the final physician approved plan which is ready for treatment at the machine. Based on the FMEA, safety improvement methods such as automation of certain processes (e.g dose constraint checking, check tools), removal of manual transcription of patient treatment related information and staff education were implemented, although this was not the team’s objective when it was originally set up. Implementation of new checklist for initial plan check based on the FMEA analysis is in process.

Conclusion: FMEA proved to be a valuable tool of identifying vulnerabilities in our workflow and processes in generating a treatment plan and subsequently a new initial plan checklist which is both more efficient and effective.


Not Applicable / None Entered.


TH- External beam- photons: General (most aspects)

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