A brachytherapy process review and TG100 failure mode effect analysis during replacement of a brachytherapy system.

Background and Purpose: To report on implementation of a brachytherapy process review and failure mode effect analysis, used to develop a prospective quality management program for the treatment of cervical cancer, whilst changing brachytherapy equipment to different vendor. Methods: During a change of vendor of brachytherapy equipment, a brachytherapy process review was undertaken, as a multidisciplinary team, using a plan, check, do, act management technique. Using the process map developed, brachytherapy failure modes were identified. Failure modes were scored based on severity, occurrence and detectability. Fault tree analysis was then undertaken for failure modes of higher risk, as per the AAPM TG100 recommendations. Results: A comprehensive brachytherapy process map was developed, from which 85 failure modes were identified. Risk probability scores ranged from 7 to 500. 39 failure modes were identified for failure mode effect analysis, either due to high risk probably scores or high severity scores. This resulted in documented procedures being developed, roles and responsibilities attributed to different team members and quality management checks being put into place. Prospective quality management techniques were utilized for reviewing the entire brachytherapy commissioning and treatment processes. Conclusions: Using a process review and failure mode effect analysis enabled a more robust brachytherapy process, with clearer responsibilities defined and enabling prospective quality management to be developed.

Emily Flower

Crown Princess Mary Cancer Centre, Westmead
Senior Radiation Oncology Medical Physicist

Emily Flower is a senior radiation oncology medical physicist from the Crown Princess Mary Cancer Centre, Westmead. She is currently completing a PhD through the Institute of Medical Physics with the University of Sydney, studying quality management in advanced brachytherapy.