FMEA of manual and automated methods for commissioning a radiotherapy treatment planning system. 2017

Amy Wexler, and Bruce Gu, and Sreekrishna Goddu, and Maya Mutic, and Sridhar Yaddanapudi, and Lindsey Olsen, and Taylor Harry, and Camille Noel, and Todd Pawlicki, and Sasa Mutic, and Bin Cai
Nuclear Science and Engineering Institute, Lafferre Hall, University of Missouri, Columbia, MO, 65211, USA.

OBJECTIVE To evaluate the level of risk involved in treatment planning system (TPS) commissioning using a manual test procedure, and to compare the associated process-based risk to that of an automated commissioning process (ACP) by performing an in-depth failure modes and effects analysis (FMEA). METHODS The authors collaborated to determine the potential failure modes of the TPS commissioning process using (a) approaches involving manual data measurement, modeling, and validation tests and (b) an automated process utilizing application programming interface (API) scripting, preloaded, and premodeled standard radiation beam data, digital heterogeneous phantom, and an automated commissioning test suite (ACTS). The severity (S), occurrence (O), and detectability (D) were scored for each failure mode and the risk priority numbers (RPN) were derived based on TG-100 scale. Failure modes were then analyzed and ranked based on RPN. The total number of failure modes, RPN scores and the top 10 failure modes with highest risk were described and cross-compared between the two approaches. RPN reduction analysis is also presented and used as another quantifiable metric to evaluate the proposed approach. RESULTS The FMEA of a MTP resulted in 47 failure modes with an RPNave of 161 and Save of 6.7. The highest risk process of "Measurement Equipment Selection" resulted in an RPNmax of 640. The FMEA of an ACP resulted in 36 failure modes with an RPNave of 73 and Save of 6.7. The highest risk process of "EPID Calibration" resulted in an RPNmax of 576. CONCLUSIONS An FMEA of treatment planning commissioning tests using automation and standardization via API scripting, preloaded, and pre-modeled standard beam data, and digital phantoms suggests that errors and risks may be reduced through the use of an ACP.

UI MeSH Term Description Entries
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000072232 Radiation Dosimeters Devices that measure exposure to IONIZING RADIATION. Dosimeters,Radiation Dosimeter,Dosimeter,Dosimeter, Radiation,Dosimeters, Radiation
D001331 Automation Controlled operation of an apparatus, process, or system by mechanical or electronic devices that take the place of human organs of observation, effort, and decision. (From Webster's Collegiate Dictionary, 1993) Automations
D012308 Risk Management The process of minimizing risk to an organization by developing systems to identify and analyze potential hazards to prevent accidents, injuries, and other adverse occurrences, and by attempting to handle events and incidents which do occur in such a manner that their effect and cost are minimized. Effective risk management has its greatest benefits in application to insurance in order to avert or minimize financial liability. (From Slee & Slee: Health care terms, 2d ed) Hospital Incident Reporting,Incident Reporting, Hospital,Hospital Incident Reportings,Incident Reporting,Incident Reportings, Hospital,Management, Risks,Reporting, Hospital Incident,Reportings, Hospital Risk,Voluntary Patient Safety Event Reporting,Hospital Risk Reporting,Hospital Risk Reportings,Incident Reportings,Management, Risk,Reporting, Hospital Risk,Reporting, Incident,Reportings, Hospital Incident,Reportings, Incident,Risk Reporting, Hospital,Risk Reportings, Hospital,Risks Management
D018570 Risk Assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. (Last, Dictionary of Epidemiology, 1988) Assessment, Risk,Benefit-Risk Assessment,Risk Analysis,Risk-Benefit Assessment,Health Risk Assessment,Risks and Benefits,Analysis, Risk,Assessment, Benefit-Risk,Assessment, Health Risk,Assessment, Risk-Benefit,Benefit Risk Assessment,Benefit-Risk Assessments,Benefits and Risks,Health Risk Assessments,Risk Analyses,Risk Assessment, Health,Risk Assessments,Risk Benefit Assessment,Risk-Benefit Assessments

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