Sub-process | N | Potential failure mode | Potential causes of failure | Potential effects of failure | S | O | D | RPN |
---|---|---|---|---|---|---|---|---|
IX. Patient’s instruction on how to request the intervention of the technician in case of need (voice call via intercom and/or lifting a hand) | 1 | Absent or insufficient patient’s information on the request for help in case of need | Negligence, difficult communication with the patient, inattention, haste (intensive scheduling) | Lack of assistance in case of need, discomfort to the patient | 10 | 1 | 3 | 30 |
XVI. Verifying the right vision of the patient from the control room with swiveling cameras | 2 | Failure to verify the vision of the patient from the cameras, suboptimal patient’s vision | Negligence, inattention, haste (intensive scheduling), superficiality, cameras not working, presence of objects in the treatment room that limit the vision of the patient | Lack of monitoring (i) possible collisions between the treatment manipulator and the patient; (ii) the patient’s welfare; (iii) possible collisions between the treatment manipulator and any object present in the treatment room. Lack of action in anomalous situations; treatment not in accordance with the planned one; postponement of the treatment session | 10 | 1 | 3 | 30 |
XVIII. Checking the correctness of patient and treatment plan data, check that the Synchrony field displays “Yes” | 3 | Failure to verify the patient and treatment data correctness, failure to verify that the Synchrony field is active | Negligence, inattention, haste (intensive scheduling), interruption of the activity, patient clinical record not present at the time of treatment | Wrong dose delivery (in case of wrong prescription of dose or number of fractions in the planning stage), elongation of the work time, unnecessary live X-ray images acquisition, postponement of the treatment session | 10 | 2 | 8 | 160 |
XXX. Selection of the appropriate size of the safety zone (small/medium/large), based on the patient’s size | 4 | Not appropriate selection of the size of the safety zone | Negligence, superficiality, inattention, haste (intensive scheduling), wrong estimate of the actual size of the patient | Risk of collision between the treatment manipulator and the patient (if PDP alerts are ignored), elongation of the treatment time (for PDP alerts) | 10 | 2 | 2 | 40 |
XXXVIII. At the end of each session, compilation of the specific section in the worklist by the technician who delivered the treatment | 5 | Missed/wrong/partial/not clear compilation of the worklist at the end of each session | Negligence, inexperience, inattention, haste (intensive scheduling), interruption of the activity, patient clinical records not present at the end of the treatment, shift of technicians during the treatment (high workload) | Incorrect delivery of treatment plans (wrong plan, wrong day,…) if multiple lesions (plans) are present, incomplete patient clinical records, slowdown of the workflow. | 8 | 2 | 5 | 80 |