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Session: Therapy General ePoster Viewing [Return to Session]

Failure Modes and Effects Analysis (FMEA) for Multi-Site, Multi-Institutional Deep Inspiration Breath Hold (DIBH) Treatments

M diMayorca*, S Wadi-Ramahi, R Lalonde, T Wilhite, S Ellsworth, A Hays, M Huq, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, PA


PO-GePV-T-160 (Sunday, 7/25/2021)   [Eastern Time (GMT-4)]

Purpose: Deep inspiration breath hold (DIBH) is a motion management technique used for various treatments, notably left breast irradiation. We performed a multi-institutional TG100 recommended risk analysis of DIBH for lung, abdomen and breast irradiations to identify where quality management can be improved.

Methods: A detailed process map was outlined for DIBH treatments of both institutions and fault tree analysis (FTA) of all potential failure modes (FM) was performed. A team comprised of two radiation oncologists, four physicists and one radiation therapist ranked occurrence (O), severity (S) and detectability (D) on a 1 to 10 scale. Ranking was subjective based on personal expertise treating DIBH within each center. FMs with the both the highest risk priority number (RPN) and highest severity scores were considered top priority and fault tree analysis was examined to identify ways to improve our workflow.

Results: The process of DIBH treatment was divided into four sub-processes: motion study, DIBH image acquisition, treatment planning, and treatment delivery, each with multiple steps. We identified 22 FM’s for the motion study sub-process, 52 for DIBH image acquisition, 8 for treatment planning and 20 for treatment delivery, for a total of 102. The RPN scores ranged from 12-245, 36-120, 18-150 and 24-144 for each sub-process respectively. The severity scores ranged 3-5 for each sub-process. Many quality assurance and control steps have been suggested for clinical implementation based on this analysis.

Conclusion: FMEA analysis revealed portions of inconsistent workflow and areas needing quality management. The analysis will be discussed to improve the workflow and quality of patient care.



    Risk, Organ Motion, Quality Control


    Not Applicable / None Entered.

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