title: Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy.
abstract: OBJECTIVE
  To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method.
  
  
  METHODS
  The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers). The failure modes with the highest risk priority numbers were then considered to implement process improvement measures.
  
  
  RESULTS
  A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures.
  
  
  CONCLUSIONS
  Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.
authors.affiliation: University of California Davis Medical Center, Sacramento, CA, USA. julian.perks@ucdmc.ucdavis.edu
authors.forename: Julian R
authors.initials: JR
authors.lastname: Perks
authors.forename: Sinisa
authors.initials: S
authors.lastname: Stanic
authors.forename: Robin L
authors.initials: RL
authors.lastname: Stern
authors.forename: Barbara
authors.initials: B
authors.lastname: Henk
authors.forename: Marsha S
authors.initials: MS
authors.lastname: Nelson
authors.forename: Rick D
authors.initials: RD
authors.lastname: Harse
authors.forename: Mathew
authors.initials: M
authors.lastname: Mathai
authors.forename: James A
authors.initials: JA
authors.lastname: Purdy
authors.forename: Richard K
authors.initials: RK
authors.lastname: Valicenti
authors.forename: Allan D
authors.initials: AD
authors.lastname: Siefkin
authors.forename: Allen M
authors.initials: AM
authors.lastname: Chen
mesh_terms: D002138:Calibration; D002289:Carcinoma, Non-Small-Cell Lung / Q000601:surgery*; D057189:Checklist; D006283:Health Physics; D006801:Humans; D007103:Immobilization / Q000379:methods*; D008175:Lung Neoplasms / Q000601:surgery*; D009068:Movement; D058996:Quality Improvement / Q000592:standards; D018787:Radiation Oncology; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D061106:Radiotherapy Setup Errors / Q000517:prevention & control*; D061089:Radiotherapy, Image-Guided; D012306:Risk