Poster - Thur Eve - 19: Risk assessment of clinical radiation processes using failure modes and effect analysis

Area of Science:

• Medical Physics
• Radiation Oncology
• Quality Improvement in Healthcare

Background:

• Analysis of 2506 adverse incidents over 5 years revealed an unexpectedly high number in the on-call radiation planning and treatment process.
• The tomotherapy process, conversely, showed a lower-than-expected incident rate.

Purpose of the Study:

• To apply Failure Modes and Effect Analysis (FMEA) to quantitatively assess and compare risks in two distinct radiation planning and treatment processes: on-call (out-of-clinical hours) and tomotherapy.
• To identify and prioritize feasible process improvements for radiation therapy workflows.

Main Methods:

• Detailed process mapping was conducted for three on-call scenarios: current workflow, workflow with software upgrade, and a fully integrated single-platform system.
• A multidisciplinary group identified potential failure modes, their effects, and existing controls for each process step.
• Risk probability numbers were calculated based on severity, frequency of occurrence, and detectability scores.

Main Results:

• The current on-call workflow was identified as incurring the highest risk among the analyzed scenarios.
• The study quantitatively demonstrated the value of a software upgrade in reducing planning steps and associated risks.
• FMEA proved to be a feasible tool for relative risk assessment in clinical processes.

Conclusions:

• Failure Modes and Effect Analysis (FMEA) is a viable method for evaluating risk in clinical radiation therapy processes.
• Implementing software upgrades and integrated platforms can significantly mitigate risks in on-call radiation planning and treatment.
• While FMEA is effective for risk assessment, operational and resource considerations require separate evaluation.