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Using Failure Mode and Effects Analysis to Determine the Incident Learning System Clinical Action Scale


J Johnson

J Johnson*, M Gillin, S Bilton, L Court, A Evans, S Harrelson, S Hayden, J Kanke, S Kirsner, M Palmer, B Riley, P Sackett, J Tonigan, G Walker, X Zhu, P Das, G Ibbott, UT MD Anderson Cancer Center, Houston, TX

PO-BPC-Exhibit Hall-3 Saturday  Room: Exhibit Hall

Purpose: Published incident learning consensus recommendations allow incidents to be classified at the local clinic level using an internally developed clinical action scale. A large, academic radiation oncology practice used failure mode and effects analysis (FMEA) as a multidisciplinary, systematic and consensus approach to revise its local clinical action scale.

Methods: From September to December 2013, a multidisciplinary team was formed, consisting of medical physicists, dosimetrists, therapists and radiation oncologists. The team met as a group, and individually completed an FMEA designed survey. The survey consisted of eighty-one published incident learning structure process steps, each with a 1-10 scale for the likelihood of occurrence (O), detectability (D), and severity (S). Completed surveys were used to calculate the average risk priority number (RPN) (OxDxS) for each process step; the process steps were ranked from highest to lowest RPN and evenly divided into three relative risk groups (high, intermediate, and low). Through discussion, the team made minor adjustments and finalized its local clinical action scale.

Results: The time required for each team member was approximately 2 and 5 hours for surveys and discussion, respectively. The process step average RPNs ranged from 194.3 (highest) to 28.3 (lowest). 81 process steps were evenly divided into three relative risk groups: high (RPNs 194.3 to 93.5), intermediate (RPNs 91.4 to 74.3) or low (RPNs 74.1 to 28.3). Review and discussion of the groupings showed high agreement, with only ten recommended group changes, corresponding to 12% of the process steps.

Conclusion: FMEA is an effective way for a multidisciplinary team to systematically come to a consensus and determine the local clinical action scale in the incident learning system. Although there is variability in the actual RPN value given to individual processes, there is much more agreement on whether each process is high, intermediate, or low relative risk.

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