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Risk Assessment for a Low Dose Rate (LDR) Prostate Brachytherapy Procedure Using Failure Modes and Effects Analysis (FMEA)

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S Cheong

S Cheong1*, J Kim1 , C Houser1 , R Smith1 , (1) UPMC, Pittsburgh, PA


SU-I-GPD-T-238 (Sunday, July 30, 2017) 3:00 PM - 6:00 PM Room: Exhibit Hall

Purpose: The aim of the study is the application of a Failure Modes and Effects Analysis (FMEA) to evaluate the risks to patients undergoing a Low Dose Rate (LDR) Prostate Brachytherapy Treatment.

Methods: FMEA was applied to identify all the sub processes involved in the treatment of a patient with LDR prostate brachytherapy, including consultation, treatment preparation, treatment delivery, and follow-up. The potential failure modes along with their causes and effects were recognized and ranked in order of their importance. Three factors were assigned for each failure mode: the occurrence rating (O), the severity rating (S), and the lack of detectability rating (D). A ten-point scale was used to score each category, ten being the number indicating most severe, most frequent, and least detectable failure mode, respectively. The risk priority number (RPN) was calculated as a product of the three attributes: RPN = O x S x D. The analysis was carried out by a working group (WG) at UPMC.

Results: The total of 57 process steps were identified for LDR Prostate Brachytherapy treatment. For each process step, the potential failure mode was evaluated by analyzing its causes and effect. In addition to the protocols already adopted in the clinical practice, the prioritized risk management will be implemented to the high risk procedures on the basis of RPN score.

Conclusion: FMEA was verified to be useful in the treatment course of the LDR prostate brachytherapy patient population. The FMEA methodology provides a structured and detailed assessment method for the risk analysis of the LDR Prostate Brachytherapy Procedure and can be applied to other types of radiation treatment.

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