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A Team Focused Clinical Implementation and Failure Mode and Effects Analysis of HDR Skin Brachytherapy Using Valencia and Leipzig Surface Applicators

E Sayler

E Sayler*, A Harrison , H Eldredge-Hindy , J Dinome , S Munro , R Anne , E Comber , V Lockamy , Bodine Center for Cancer Treatment, Thomas Jefferson University, Philadelphia, PA


SU-C-BRD-2 Sunday 1:00PM - 1:55PM Room: Ballroom D


Valencia and Leipzig applicators (VLAs) are single-channel brachytherapy surface applicators used to treat skin lesions up to 2cm diameter. Source dwell times can be calculated and entered manually after clinical set-up or ultrasound. This procedure differs dramatically from CT-based planning; the novelty and unfamiliarity could lead to severe errors. To build layers of safety and ensure quality, a multidisciplinary team created a protocol and applied Failure Modes and Effects Analysis (FMEA) to the clinical procedure for HDR VLA skin treatments.


A team including physicists, physicians, nurses, therapists, residents, and administration developed a clinical procedure for VLA treatment. The procedure was evaluated using FMEA. Failure modes were identified and scored by severity, occurrence, and detection. The clinical procedure was revised to address high-scoring process nodes.


Several key components were added to the clinical procedure to minimize risk probability numbers (RPN):
-Treatments are reviewed at weekly QA rounds, where physicians discuss diagnosis, prescription, applicator selection, and set-up. Peer review reduces the likelihood of an inappropriate treatment regime.
-A template for HDR skin treatments was established in the clinical EMR system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planning physicist, and increases the detectability of an error during the physics second check.
-A screen check was implemented during the second check to increase detectability of an error.
-To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display. This facilitates data entry and verification.
-VLAs are color-coded and labeled to match the EMR prescriptions, which simplifies in-room selection and verification.


Multidisciplinary planning and FMEA increased delectability and reduced error probability during VLA HDR Brachytherapy. This clinical model may be useful to institutions implementing similar procedures.

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