Poster - Thur Eve - 38: Review of couch parameters using an FMEA

Area of Science:

• Medical Physics
• Radiation Oncology
• Patient Safety

Background:

• Patient positioning accuracy is critical in radiation therapy.
• Deviations in couch position can lead to treatment errors and compromised patient safety.
• Existing processes for obtaining couch positions require systematic evaluation for potential failure modes.

Purpose of the Study:

• To systematically review and improve patient positioning processes.
• To identify and mitigate failure modes affecting couch position accuracy.
• To enhance patient safety during radiation therapy treatments.

Main Methods:

• Utilized a Failure Mode and Effects Analysis (FMEA) framework.
• Identified and rated fifteen potential failure modes in couch positioning.
• Analyzed the impact of identified failures, particularly overrides of couch parameters.

Main Results:

• Identified three major failures: loss of planned position, differing DICOM origins/isocenters, and unintended patient shifts.
• Implemented process modifications, new quality assurance (QA) checks, software enhancements, and tolerance tables.
• Reduced couch parameter overrides from a maximum of 20.5% to 6.3%, averaging 4% in daily treatments.

Conclusions:

• Failure Mode and Effects Analysis (FMEA) is an effective tool for improving radiation therapy treatment quality.
• Systematic review and modification of positioning processes enhance system robustness.
• The implemented changes significantly increased the success rate of catching failures before patient impact.