Risk Assessment for Stereotactic Intracranial Radiosurgery (SRS) in Brazil Using FMEA
F Teixeira*,CNEN - COMISSAO NACIONAL DE ENERGIA NUCLEAR , BRAZIL AND UERJ - UNIVERSIDADE DO RIO DE JANEIRO, Rio de Janeiro, Brazil C de ALMEIDA, UERJ - UNIVERSIDADE DO RIO DE JANEIRO, Rio De Janeiro, RIO DE JANEIROSU-E-T-240 Sunday 3:00PM - 6:00PM Room: Exhibit Hall
The purpose of this work is develop a study capable of help the radiotherapy centers to apply a quality management program based on a process analysis methods with the application of failure mode and effect analysis (FMEA) to stereotactic radiosurgery.
This (FMEA) methodology has been tested initially in two radiotherapy centers, both of which perform SRS with a linear accelerator Novalis using a 6 MV of photon beam.The FMEA method allows documenting potential failure modes, determining its effects, identifying causes of failures, developing plans, documenting team concurrence and actions taken.The FMEA method determines a value to the risk probability number (RPN) for each potential cause of failure using the product of three categories: O, the probability that a specific cause will result in a failure mode; S, the severity of the effects resulting from a specific failure mode; D, the probability that the failure mode will be detected.
This work presents preliminary results and shows that the most failures are somewhat related of the human factors issues. It have been already found values 38 sub process and it was identified 59 different potential failure modes and 140 potential causes of failure. Among the potential cause of failure mode 40,7% can be considered an error associated to human factors issues. The larger value for RPN was 432 and the lower was 12.
Although FMEA contains a very subjective component, it is a useful and simple tool for prospective risk assessment with respect to patient care. This work is still in development but it is already possible to conclude that some conditions for operating are indispensable to achieving a high quality in patient care, such as: adequate training, clear procedures, clear level of the responsibility.