Table 2 Interventions resulting from the FMEA process
Rank | Failure mode | Preventative measure |
|---|---|---|
A: K C I—F M E A | ||
 1 | Patient moves after setup (with lung blocks) | Increased attentiveness to patient motion—one therapist assigned solely to monitoring patient motion |
 2 | Setup error (significant wrt tx field) | Check of treatment field via light field visualization prior after setup and prior to treatment |
 3 | Calculation error | Second check of calculation by physicist |
 4 | Couch is accidentally shifted after morning QA (shift insignificant wrt tx field) | Therapists check couch location again after patient setup and prior to treatment |
 5 | Program wrong tx time | Time out and double check by second therapist |
 6 | Patient moves after setup (significant move wrt tx field) (no lung blocks) | Increased attentiveness to patient motion—one therapist assigned solely to monitoring patient motion |
 7 | Used prone time for supine position or vice versa | Time out and double check by second therapist |
 8 | Timer malfunction | Set stopwatch as secondary timer for all multi-fraction cases |
 9 | Missing lung blocks (one fraction) | Time out and double check by second therapist |
 10 | Incorrect documentation (patient positioning) | Measurements rechecked during setup on each treatment day |
 11 | Incorrect lung block design/size | Evaluation of lung block size and shape prior to first treatment |
 12 | Forget to flip to supine after prone field | Time out and double check by second therapist |
 13 | Incorrect mx | Measurements rechecked during setup on each treatment day |
 14 | Corrupt spreadsheet | Checked against manual calculation for all treatment fields |
 15 | Image from wrong date is used for alignment verification | Lung blocking evaluated against anatomy on the current blocked image |
 16 | Patient has too many blankets covering them | Checked prior to treatment |
 17 | Incorrect documentation (patient measurements) | Measurements rechecked during setup on each treatment day |
 18 | Couch is accidentally shifted after morning QA (shift significant wrt tx field) | Therapists check couch location again after patient setup and prior to treatment |
 19 | Images saved under wrong patient | Lung blocking evaluated against anatomy on the current blocked image |
 20 | Miscommunication of Rx | Physicist checks BMT physician’s treatment note in addition to RO physician’s treatment note |
B. D F B W – F M E A | ||
 1 | Corrupt spreadsheet | Calculation performed by both a commissioned Java application and a spreadsheet |
 2 | Neglect to subtract in-vivo delivery time from remaining tx time | Time out and double check by second therapist |
 3 | Setup error (significant wrt tx field) | Check of treatment field via light field visualization after setup and prior to treatment |
 4 | Program wrong tx time | Time out and double check by second therapist |
 5 | Incorrect compensator placement | Compensator placement is checked before treatment with MV imaging |
 6 | Calculation error | Two independent calculations are performed, one by dosimetry one by physics |
 7 | Incorrect treatment date | Correct dates are second checked during physics check and therapist plan check |
 8 | Miscommunication of Rx | Physics 2nd check compares planned dose to prescription Therapist plan check compares planned dose to prescription |
 9 | Incorrect documentation in EMR | Fractionation checked against a protocol list |
 10 | Timer malfunction | Secondary timer used during all treatments |
 11 | Plan changed after checks but before approval on tx day | Timeout compares planned dose to prescription on tx day |
 12 | Flattening filter partially inserted | Flattening filter position checked during morning QA |
 13 | Flattening filter inserted but not latched | Flattening filter position checked during morning QA |
 14 | Incorrect compensator | Compensators are checked against plan during therapist plan check |
 15 | Incorrect documentation | Plan documentation checked during physics check and therapist plan check |
 16 | Miscommunication of dates | Correct dates are second checked during physics check and therapist plan check |
 17 | Wrong flattening filter inserted | The console will interlock if the wrong flattening filter is inserted and distance from the floor to the flattening filter would fail QA if wrong filter was in place |
 18 | Wrong compensator | Compensators are checked against plan during therapist plan check |
 19 | Patient moves after setup (significant move wrt tx field) (no lung blocks) | Increased attentiveness to patient motion—one therapist assigned solely to monitoring patient motion |
 20 | Wrong lung blocks | Lung blocks are checked against plan during therapist plan check |