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http://dx.doi.org/10.7742/jksr.2017.11.7.627

Study of Failure Mode and Effect Analysis in Brachytherapy  

Lee, Soon Sung (University of Science and Technology, Radiological & Medico Oncological Sciences)
Park, Dong Wook (Department of Radiation Oncology, Inje Ilsan Paik University Hospital)
Shin, Dong Oh (Department of Radiation Oncology, Kyung Hee University Hospital)
Kim, Dong Wook (Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong)
Kim, Kum Bae (Division of Medical Radiation Equipment, Korea Institute of Radiological and Medical Sciences)
Oh, Yoon-Jin (Research Institute of Clinical Medicine, Kyung Hee University Hospital at Gangdong)
Kim, Juhye (Research Institute of Clinical Medicine, Kyung Hee University Hospital at Gangdong)
Kwon, Na Hye (Research Institute of Clinical Medicine, Kyung Hee University Hospital at Gangdong)
Kim, Kyeong Min (University of Science and Technology, Radiological & Medico Oncological Sciences)
Choi, Sang Hyoun (University of Science and Technology, Radiological & Medico Oncological Sciences)
Publication Information
Journal of the Korean Society of Radiology / v.11, no.7, 2017 , pp. 627-635 More about this Journal
Abstract
Brachytherapy is generally performed in conjunction with external radiation therapy, and the treatment course is very complicated, which can lead to radiation accidents. In order to solve this problem, we designed the process map by applying the failure mode and effects analysis (FMEA) method to the Brachytherapy and scored the risk priority number (RPN) for each treatment course based on this process map. The process map consisted of five steps, Patient consulting", "Brachytherapy simulation", "CT simulation", "Brachytherapy treatment planning" and "Treatment". In order to calculate the RPN, doctor, medical physicist, dose planners, therapist, and nurse participated in the study and evaluated occurrence, severity, and lack of detectability at each detail step. Overall, the process map is preceded by a patient identification procedure at each treatment stage, which can be mistaken for another patient, and a different treatment plan may be established to cause a radiation accident. As a result of evaluating the RPN for the detailed steps based on the process map, overall "Patient consulting" and "Brachytherapy treatment planning" step were evaluated as high risk. The nurses showed a tendency to be different from each other, and the nurses had a risk of 55 points or more for all the procedures except "Treatment", and the "Brachytherapy simulation" step was the highest with 88.8 points. Since the treatment stage differs somewhat for each medical institution performing radiotherapy, it is thought that the risk management should be performed intensively by preparing the process map for each institution and calculating the risk RPN.
Keywords
Failure Mode and Effect Analysis; Brachytherapy; Process map; Risk Priority Number; Risk management;
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Times Cited By KSCI : 1  (Citation Analysis)
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