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Results of Applying FMEA and Fault Tree Analysis to the Online Incident Reporting Database


T Nurushev

T Nurushev*, B Miller, M Dickinson, A Esposito, B Movsas, M Siddiqui, I Chetty, Henry Ford Health System, Detroit, MI

MO-D-105-7 Monday 2:00PM - 2:55PM Room: 105

Purpose: As part of the continuous quality of care improvement, an internal online database for processing reported incidents was established. In 3 years, 710 incidents were reported by 5 clinics. We have ranked the fault trees of the reported incidents using the AAPM report TG-100 Failure Mode and Effects Analysis (FMEA) tools

Methods:Risk Probability Number (RPN) generated as a result of applying FMEA is based on the severity, probability of occurrence and probability of going undetected. The reports were sorted in two categories. Potentially affecting dose delivery, e.g. incorrect setup instructions; and deviations from an established workflow defined by policies and procedures (P&P), e.g., incorrect naming of the fields. In addition to FMEA, the impact of new, as well as periodic reviews of P&P by staff members is assessed

Results:Of 710 reports 676 were analyzed, 374 were variation in the workflow not directly affecting quality of care, 302 were potentially affecting dose delivery. 19 of 302 had dosimetric impact; however, due to low occurrence only 4 instances, related to bolus placement, reached the RPN above 200. Review of current P&P reduced the RPN from 270 to 9. Periodic review, introduction of the new or revising the existing P&P had a dual effect: drop in dose-affecting incidents and increased reporting of process deviations

Conclusion:Analysis of reported incidents and review by the departmental QA committee is an essential part of any QA program. By defining the fault trees and applying FMEA to the reported incidents, we were able to reduce the RPN from an average of 150 for dose related incidents to 9, and for process variations from 295 to 28 on average. Event-triggered revising of P&Ps and periodic review with staff of the existing P&P is an effective tool in incident reduction

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