SU-E-T-128: Applying Failure Modes and Effects Analysis to a Risk-Based Quality Management for Stereotactic Radiosurgery in Brazil
Purpose: The goal of the present work was to evaluate the process maps for stereotactic radiosurgery (SRS) treatment at three radiotherapy centers in Brazil and apply the FMEA technique to evaluate similarities and differences, if any, of the hazards and risks associated with these processes. Methods: A team, consisting of professionals from different disciplines and involved in the SRS treatment, was formed at each center. Each team was responsible for the development of the process map, and performance of FMEA and FTA. A facilitator knowledgeable in these techniques led the work at each center. The TG100 recommended scales were used for the evaluation of hazard and severity for each step for the major process “treatment planning”. Results: Hazard index given by the Risk Priority Number (RPN) is found to range from 4–270 for various processes and the severity (S) index is found to range from 1–10. The RPN values > 100 and severity value ≥ 7 were chosen to flag safety improvement interventions. Number of steps with RPN ≥100 were found to be 6, 59 and 45 for the three centers. The corresponding values for S ≥ 7 are 24, 21 and 25 respectively. The range of RPN and S values for each center belong to different process steps and failure modes. Conclusion: These results show that interventions to improve safety is different for each center and it is associated with the skill level of the professional team as well as the technology used to provide radiosurgery treatment. The present study will very likely be a model for implementation of risk-based prospective quality management program for SRS treatment in Brazil where currently there are 28 radiotherapy centers performing SRS. A complete FMEA for SRS for these three radiotherapy centers is currently under development.