Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy

Julian R Perks, Sinisa Stanic, Robin L Stern, Barbara Henk, Marsha S. Nelson, Rick D. Harse, Mathew Mathai, James A. Purdy, Richard K Valicenti, Allan D. Siefkin, Allen M. Chen

Research output: Contribution to journalArticle

40 Citations (Scopus)

Abstract

Purpose: To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. Methods: The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers). The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. Results: A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. Conclusion: Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.

Original languageEnglish (US)
Pages (from-to)1324-1329
Number of pages6
JournalInternational Journal of Radiation Oncology Biology Physics
Volume83
Issue number4
DOIs
StatePublished - Jul 15 2012

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failure modes
lungs
radiation therapy
delivery
Radiotherapy
Lung
occurrences
safety
Safety
gantry cranes
Process Assessment (Health Care)
Checklist
Healthcare Failure Mode and Effect Analysis
Therapeutics

Keywords

  • Failure mode and effects analysis
  • Process improvement
  • Quality assurance
  • Safety
  • Stereotactic body radiation therapy

ASJC Scopus subject areas

  • Oncology
  • Radiology Nuclear Medicine and imaging
  • Radiation
  • Cancer Research

Cite this

Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. / Perks, Julian R; Stanic, Sinisa; Stern, Robin L; Henk, Barbara; Nelson, Marsha S.; Harse, Rick D.; Mathai, Mathew; Purdy, James A.; Valicenti, Richard K; Siefkin, Allan D.; Chen, Allen M.

In: International Journal of Radiation Oncology Biology Physics, Vol. 83, No. 4, 15.07.2012, p. 1324-1329.

Research output: Contribution to journalArticle

Perks, Julian R ; Stanic, Sinisa ; Stern, Robin L ; Henk, Barbara ; Nelson, Marsha S. ; Harse, Rick D. ; Mathai, Mathew ; Purdy, James A. ; Valicenti, Richard K ; Siefkin, Allan D. ; Chen, Allen M. / Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. In: International Journal of Radiation Oncology Biology Physics. 2012 ; Vol. 83, No. 4. pp. 1324-1329.
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