FMEA of the simulation CT in a RT department: lesson learned by radiation oncologists in training
PO-1101
Abstract
FMEA of the simulation CT in a RT department: lesson learned by radiation oncologists in training
Authors: Pietro Mancosu1, Chiara Signori2, Damiano Dei3, Nicola Lambri4, Luciana Di Cristina4, Lorenzo Lo Faro4, Beatrice Marini4, Antonio M Marzo4, Sara Stefanini4, Veronica Vernier4, Stefano Tomatis1, Marta Scorsetti4
1IRCCS Humanitas Research Hospital, Radiotherapy and Radiosurgery, Rozzano (Milano), Italy; 2IRCCS Humanitas Research Hospital, Risk Management Unit, Rozzano (Milano), Italy; 3Humanitas University; IRCCS Humanitas Research Hospital, Radiotherapy and Radiosurgery , Rozzano (Milano), Italy; 4Humanitas University; IRCCS Humanitas Research Hospital, Radiotherapy and Radiosurgery, Rozzano (Milano), Italy
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Purpose or Objective
Risk analysis is part of the radiation oncology training as recommended by the 2013/59/Euratom directive. Failure Mode and Effect Analysis (FMEA) is a proactive methodology that allows to analyze a process and to evaluate the risk connected, regardless of whether an adverse event occurs. In this study, the simulation CT process was analyzed using FMEA approach by radiation oncologists (ROs) in training and was validated by expert ROs.
Material and Methods
An eight-hours course, led by two clinical risk experts, was performed during the school of specialization in RO to illustrate the risk analysis approaches. During this course, the six ROs in training, helped by the two experts, performed a detailed process analysis of the CT simulation and evaluated the possible Failure Modes (FMs). For each FM, the estimated frequency of occurrence (O – range 1-4), the expected severity of the damage (S – range 1-5) and the detectability lack (D – range 1-4) were scored independently by the six ROs. A risk priority number (RPN) was obtained as RPN=OxSxD. The RPN values were compared to the values obtained by a group of six ROs experts of the same department.
Results
Thirty-six FMs were identified by the group in training. Similar mean RPN values were obtained by the two groups (13.5 vs 13.6). Larger standard deviation in evaluating each FMs was observed for the ROs in training (9.0 vs. 6.5), probably due to different level of experience. Both groups ranked the following FMs as highest priorities: (i) the patient identification; (ii) the missing of clinical documentation; (iii) the physical examination; (iv) A non-adequate patient preparation. Leveraging on the experiences gained during training in other hospitals, the group proposed a pre-exam carried out by the ROs in training to verify the adequacy of the previous clinical documentation and check the patient preparation as a corrective action to reduce higher RPNs.
Conclusion
This study revealed the importance of a risk management culture for ROs in training. This study helped in increasing the safety of CT simulation process.