Rank | FM# | Process description | Step description | Failure mode | Effects | O | S | D | RPN |
---|---|---|---|---|---|---|---|---|---|
A: K C I – F M E A (7 scorers: 3 MPs, 2 ROs, 2 RTs) ranked wrt mean RPN scores | |||||||||
 1 | 54 | Treatment | Delivery | Patient moves after setup (with lung blocks) | Incorrect dose delivered | 4.6 (2.1) | 6.0 (0.6) | 3.8 (1.9) | 104.9 (72) |
 2 | 16 | Treatment | Setup | Setup error (significant wrt tx field) | Incorrect dose delivered | 3.3 (2.3) | 5.8 (1.8) | 4.8 (3.3) | 88.8 (92.4) |
 3 | 8 | Planning | Preparation of initial plan | Calculation error | Incorrect dose calculation | 4.4 (3.1) | 7.6 (2.0) | 2.0 (0.6) | 66.9 (54.9) |
 4 | 80 | QA | Machine QA | Couch is accidentally shifted after morning QA (shift insignificant wrt tx field) | Incorrect dose delivered | 4.3 (2.6) | 3.3 (0.8) | 4.8 (1.5) | 65.6 (47.9) |
 5 | 49 | Treatment | Delivery | Program wrong tx time | Incorrect dose delivered | 3.0 (2.1) | 7.0 (2.7) | 3.0 (1.9) | 63.0 (64.1) |
 6 | 53 | Treatment | Delivery | Patient moves after setup (significant move wrt tx field) (no lung blocks) | Incorrect dose delivered | 3.6 (1.9) | 4.2 (0.4) | 4.0 (1.8) | 60.5 (41.7) |
 7 | 64 | Treatment | Delivery | Used prone time for supine position or vice versa | Incorrect dose delivered | 3.4 (2.1) | 4.4 (0.5) | 4.0 (3.3) | 59.8 (61.4) |
 8 | 52 | Treatment | Delivery | Timer malfunction | Incorrect dose delivered | 2.2 (1.2) | 7.4 (2.3) | 3.4 (1.4) | 55.4 (40.7) |
 9 | 18 | Treatment | Setup | Missing lung blocks (one fraction) | Incorrect dose delivered | 3.0 (1.7) | 4.4 (0.8) | 4.0 (3.2) | 52.8 (52.0) |
 10 | 5 | Sim | Pt positioning | Incorrect documentation | Incorrect patient setup | 3.6 (1.6) | 3.0 (1.1) | 4.8 (3.2) | 51.8 (46.2) |
 11 | 12 | Planning | Ancillary | Incorrect lung block design/size | Lung overdose / target underdose | 4.0 (3.0) | 5.8 (2.8) | 2.2 (1.0) | 51.0 (50.5) |
 12 | 63 | Treatment | Delivery | Forget to flip to supine after prone field | Incorrect dose delivered | 2.0 (1.1) | 6.8 (1.7) | 3.6 (3.4) | 49.0 (54.7) |
 13 | 3 | Sim | Pt measurements | Incorrect mx | Incorrect dose calculation | 3.8 (2.4) | 4.0 (0.6) | 3.2 (1.6) | 48.6 (39.9) |
 14 | 11 | Planning | Preparation of initial plan | Corrupt spreadsheet | Incorrect dose calculation | 3.0 (1.6) | 8.0 (0.8) | 2.0 (0.8) | 48.0 (33.0) |
 15 | 69 | Treatment | Delivery | Image from wrong date is used for alignment verification | Lung blocks positioned incorrectly | 2.8 (1.0) | 4.2 (1.0) | 4.0 (3.0) | 47.0 (40.8) |
 16 | 65 | Treatment | Delivery | Patient has too many blankets covering them | Change in dose distribution | 3.8 (2.7) | 3.6 (1.0) | 3.4 (2.2) | 46.5 (47.1) |
 17 | 4 | Sim | Pt measurements | Incorrect documentation | Incorrect dose calculation | 3.8 (2.7) | 3.8 (1.5) | 3.2 (1.7) | 46.2 (45.0) |
 18 | 81 | QA | Machine QA | Couch is accidentally shifted after morning QA (shift significant wrt tx field) | Incorrect dose delivered | 3.3 (1.5) | 5.0 (1.6) | 2.8 (1.5) | 44.7 (34.5) |
 19 | 68 | Treatment | Delivery | Images saved under wrong patient | Inability to localize lung blocks, potentially incorrect dose delivered | 3.0 (1.3) | 4.2 (1.7) | 3.4 (3.3) | 42.8 (48.9) |
 20 | 6 | Planning | Preparation of initial plan | Miscommunication of Rx | Incorrect dose or fractionation | 1.6 (0.5) | 7.0 (2.3) | 3.6 (3.4) | 40.3 (42.0) |
Rank | FM# | Process description | Step Description | Failure mode | Effects | O | S | D | RPN |
---|---|---|---|---|---|---|---|---|---|
B: K C I—F M E A (7 scorers: 3 MPs, 2 ROs, 2 RTs) ranked wrt mean ‘S’ scores | |||||||||
 1 | 42 | Treatment | Setup | Flattening filter falls on patient | Patient injury | 1.8 (1.6) | 8.4 (2) | 1.2 (0.4) | 18.1 (17.7) |
 2 | 47 | Treatment | Delivery | Wrong patient | Incorrect dose delivered | 1.4 (0.5) | 8.2 (2.1) | 1.2 (0.4) | 13.8 (7.6) |
 3 | 11 | Planning | Preparation of initial plan | Corrupt spreadsheet | Incorrect dose calculation | 3.0 (1.6) | 8.0 (0.8) | 2.0 (0.8) | 48.0 (33.0) |
 4 | 79 | QA | Machine QA | Source stuck and emergency shutter not operational | Patient overdose | 1.0 (0.0) | 8.0 (2.8) | 3.7 (3.8) | 29.3 (31.9) |
 5 | 8 | Planning | Preparation of initial plan | Calculation error | Incorrect dose calculation | 4.4 (3.1) | 7.6 (2.0) | 2.0 (0.6) | 66.9 (54.9) |
 6 | 19 | Treatment | Setup | Missing lung blocks (all fractions) | Incorrect dose delivered | 1.4 (0.8) | 7.6 (2.6) | 3.2 (3.5) | 34.0 (43.5) |
 7 | 39 | Treatment | Setup | Flattening filter not inserted | Incorrect dose delivered | 1.4 (0.5) | 7.6 (2.2) | 1.6 (0.8) | 17.0 (11.5) |
 8 | 56 | Treatment | Delivery | Source stuck | Incorrect dose delivered/staff exposure | 1.6 (0.5) | 7.6 (2.3) | 1.2 (0.4) | 14.6 (8.0) |
 9 | 52 | Treatment | Delivery | Timer malfunction | Incorrect dose delivered | 2.2 (1.2) | 7.4 (2.3) | 3.4 (1.4) | 55.4 (40.7) |
 10 | 45 | Treatment | Setup | Motor run away causing head to contact patient | Patient injury | 1.4 (0.5) | 7.4 (2.2) | 1.2 (0.4) | 12.4 (7.0) |
 11 | 28 | Treatment | Setup | Couch not at treatment height for multiple fx (large change > 5 cm) | Incorrect dose delivered | 2.0 (1.5) | 7.2 (2.3) | 1.4 (0.5) | 20.2 (18.3) |
 12 | 49 | Treatment | Delivery | Program wrong tx time | Incorrect dose delivered | 3.0 (2.1) | 7.0 (2.7) | 3 (1.9) | 63.0 (64.1) |
 13 | 6 | Planning | Preparation of initial plan | Miscommunication of Rx | Incorrect dose or fractionation | 1.6 (0.5) | 7.0 (2.3) | 3.6 (3.4) | 40.3 (42.0) |
 14 | 13 | Planning | Ancillary | Incorrect compensator | Incorrect dose delivered | 2 (1) | 7.0 (2.0) | 2.5 (1.5) | 35.0 (29.1) |
 15 | 37 | Treatment | Setup | Head not at correct treatment height for multiple fx (large change > 5 cm) | Incorrect dose delivered | 1.4 (0.5) | 7.0 (2.0) | 3.0 (3.5) | 29.4 (37.0) |
 16 | 63 | Treatment | Delivery | Forget to flip to supine after prone field | Incorrect dose delivered | 2.0 (1.1) | 6.8 (1.7) | 3.6 (3.4) | 49.0 (54.7) |
 17 | 32 | Treatment | Setup | Treatment head in wrong rotational position, not locked | Incorrect dose delivered | 1.6 (0.8) | 6.8 (1.6) | 1.4 (0.5) | 15.2 (10.0) |
 18 | 43 | Treatment | Setup | Wrong flattening filter inserted | Incorrect dose delivered | 1.0 (0.0) | 6.3 (2.6) | 4.3 (4.0) | 27.4 (27.9) |
 19 | 73 | QA | Machine QA | Incorrect calibration | Incorrect dose delivered | 2.3 (1.2) | 6.3 (2.6) | 1.3 (0.5) | 19.7 (15.0) |
 20 | 70 | Treatment | Delivery | Treatment paused but not restarted | Incorrect dose delivered | 1.8 (0.7) | 6.2 (1.7) | 3.6 (3.3) | 40.2 (41.6) |
Rank | FM# | Process description | Step Description | Failure mode | Effects | O | S | D | RPN |
---|---|---|---|---|---|---|---|---|---|
C: D F B W—F M E A (6 scorers: 2 MPs, 2 ROs, 2 RTs) ranked wrt mean RPN scores | |||||||||
1 | 11 | Planning | Preparation of initial plan | Corrupt spreadsheet | Incorrect dose calculation | 1.8 (0.7) | 7.0 (1.2) | 5.8 (2.3) | 74.9 (42.3) |
2 | 51 | Treatment | Delivery | Neglect to subtract in-vivo delivery time from remaining tx time | Incorrect dose delivered | 2.5 (0.9) | 6.5 (1.7) | 4.0 (1.9) | 65.0 (41.3) |
3 | 16 | Treatment | Setup | Setup error (significant wrt tx field) | Incorrect dose delivered | 2.5 (1.6) | 6.5 (2.1) | 3.8 (2.6) | 62.3 (61.6) |
4 | 49 | Treatment | Delivery | Program wrong tx time | Incorrect dose delivered | 2.5 (0.8) | 7.0 (1.8) | 3.5 (1.7) | 61.3 (38.7) |
5 | 14 | Planning | Ancillary | Incorrect compensator placement | Incorrect dose delivered | 2.3 (0.4) | 6.3 (1.3) | 4.0 (1.9) | 56.3 (30.8) |
6 | 8 | Planning | Preparation of initial plan | Calculation error | Incorrect dose calculation | 2.0 (0.6) | 7.2 (0.9) | 3.8 (2) | 54.9 (33.9) |
7 | 9 | Planning | Preparation of initial plan | Incorrect treatment date | Incorrect dose calculation | 2.2 (0.7) | 6.3 (1.4) | 4.0 (2.3) | 54.9 (38.1) |
8 | 6 | Planning | Preparation of initial plan | Miscommunication of Rx | Incorrect dose or fractionation | 2.2 (0.4) | 7.2 (1.1) | 3.5 (1.9) | 54.3 (31.9) |
9 | 10 | Planning | Preparation of initial plan | Incorrect documentation in EMR | Incorrect plan/dose delivered | 2.2 (0.4) | 6.2 (2.5) | 4.0 (2.5) | 53.4 (41.2) |
10 | 52 | Treatment | Delivery | Timer malfunction | Incorrect dose delivered | 1.7 (0.5) | 7.7 (1.6) | 3.8 (2.0) | 49.0 (30.3) |
11 | 2 | Logistics | Plan approval | Plan changed after checks but before approval on tx day | Incorrect plan delivered | 2.5 (0.8) | 5.3 (2.9) | 3.7 (2.1) | 48.9 (41.1) |
12 | 40 | Treatment | Setup | Flattening filter partially inserted | Incorrect dose delivered | 1.8 (0.4) | 6.7 (1.8) | 3.8 (1.6) | 46.9 (24.9) |
13 | 41 | Treatment | Setup | Flattening filter inserted but not latched | Incorrect dose delivered | 1.8 (0.4) | 5.7 (1.9) | 4.5 (2.1) | 46.8 (28.1) |
14 | 13 | Planning | Ancillary | Incorrect compensator | Incorrect dose delivered | 2.0 (0.0) | 6.5 (1.1) | 3.5 (2.1) | 45.5 (27.9) |
15 | 7 | Planning | Preparation of initial plan | Incorrect documentation | Incorrect dose calculation | 2.0 (0.0) | 7.2 (0.9) | 3.2 (1.9) | 45.4 (27.3) |
16 | 1 | Logistics | Treatment calendar | Miscommunication of dates | Plan not ready on tx date, plan calculated for wrong tx date | 3.2 (1.0) | 4.0 (2.4) | 3.5 (1.4) | 44.8 (35.4) |
17 | 43 | Treatment | Setup | Wrong flattening filter inserted | Incorrect dose delivered | 1.5 (0.5) | 6.8 (1.7) | 4.2 (2.2) | 42.7 (28.6) |
18 | 22 | Treatment | Setup | Wrong compensator | Incorrect dose delivered | 2.0 (0.7) | 6.0 (1.6) | 3.5 (2.1) | 42 (30.9) |
19 | 53 | Treatment | Delivery | Patient moves after setup (significant move wrt tx field) (no lung blocks) | Incorrect dose delivered | 2.8 (0.9) | 5.5 (2.0) | 2.7 (0.9) | 41.6 (24.8) |
20 | 17 | Treatment | Setup | Wrong lung blocks | Incorrect dose delivered | 2.2 (0.4) | 5.0 (2.0) | 3.8 (2.3) | 41.5 (30.5) |
Rank | FM# | Process description | Step Description | Failure mode | Effects | O | S | D | RPN |
---|---|---|---|---|---|---|---|---|---|
D: D F B W—F M E A (6 scorers: 2 MPs, 2 ROs, 2 RTs) ranked wrt mean ‘S’ scores | |||||||||
 1 | 47 | Treatment | Delivery | Wrong patient | Incorrect dose delivered | 1.2 (0.4) | 8.7 (0.9) | 2.7 (1.4) | 27.0 (16.6) |
 2 | 56 | Treatment | Delivery | Source stuck | Incorrect dose delivered / staff exposure | 1.2 (0.4) | 8.7 (1.1) | 1.3 (0.5) | 13.5 (6.6) |
 3 | 79 | QA | Machine QA | Source stuck and emergency shutter not operational | Patient overdose | 1.2 (0.4) | 8.3 (2.2) | 2.2 (1.5) | 21.1 (16.7) |
 4 | 42 | Treatment | Setup | Flattening filter falls on patient | Patient injury | 1.5 (0.5) | 8.2 (0.9) | 2.3 (2.1) | 28.6 (28.0) |
 5 | 45 | Treatment | Setup | Motor run away causing head to contact patient | Patient injury | 1.2 (0.4) | 8.0 (2.0) | 1.5 (0.8) | 14.0 (9.1) |
 6 | 52 | Treatment | Delivery | Timer malfunction | Incorrect dose delivered | 1.7 (0.5) | 7.7 (1.6) | 3.8 (2.0) | 49.0 (30.3) |
 7 | 25 | Treatment | Setup | Compensator falls on patient | Patient injury | 1.5 (0.5) | 7.5 (1.5) | 2.8 (3.0) | 30.9 (36.2) |
 8 | 8 | Planning | Preparation of initial plan | Calculation error | Incorrect dose calculation | 2.0 (0.6) | 7.2 (0.9) | 3.8 (2.0) | 54.9 (33.9) |
 9 | 6 | Planning | Preparation of initial plan | Miscommunication of Rx | Incorrect dose or fractionation | 2.2 (0.4) | 7.2 (1.1) | 3.5 (1.9) | 54.3 (31.9) |
 10 | 7 | Planning | Preparation of initial plan | Incorrect documentation | Incorrect dose calculation | 2.0 (0.0) | 7.2 (0.9) | 3.2 (1.9) | 45.4 (27.3) |
 11 | 28 | Treatment | Setup | Couch not at treatment height for multiple fx (large change > 5 cm) | Incorrect dose delivered | 1.8 (1.1) | 7.2 (2) | 2.8 (2.1) | 37.2 (36.8) |
 12 | 11 | Planning | Preparation of initial plan | Corrupt spreadsheet | Incorrect dose calculation | 1.8 (0.7) | 7.0 (1.2) | 5.8 (2.3) | 74.9 (42.3) |
 13 | 49 | Treatment | Delivery | Program wrong tx time | Incorrect dose delivered | 2.5 (0.8) | 7.0 (1.8) | 3.5 (1.7) | 61.3 (38.7) |
 14 | 21 | Treatment | Setup | Lung blocks/tray fall on patient | Patient injury | 1.2 (0.4) | 7.0 (1.5) | 2.0 (2.2) | 16.3 (19.3) |
 15 | 19 | Treatment | Setup | Missing lung blocks (all fractions) | Incorrect dose delivered | 1.2 (0.4) | 7.0 (1.8) | 1.5 (0.8) | 12.3 (8.0) |
 16 | 43 | Treatment | Setup | Wrong flattening filter inserted | Incorrect dose delivered | 1.5 (0.5) | 6.8 (1.7) | 4.2 (2.2) | 42.7 (28.6) |
 17 | 39 | Treatment | Setup | Flattening filter not inserted | Incorrect dose delivered | 1.8 (0.4) | 6.8 (2.0) | 3.0 (1.4) | 37.6 (22.3) |
 18 | 63 | Treatment | Delivery | Forget to flip to supine after prone field | Incorrect dose delivered | 1.7 (0.5) | 6.8 (0.7) | 2.2 (1.3) | 24.7 (17.0) |
 19 | 40 | Treatment | Setup | Flattening filter partially inserted | Incorrect dose delivered | 1.8 (0.4) | 6.7 (1.8) | 3.8 (1.6) | 46.9 (24.9) |
 20 | 74 | QA | Machine QA | Incorrect beam data | Incorrect dose delivered | 2.0 (0.6) | 6.7 (1.8) | 2.7 (1.1) | 35.6 (20.4) |