Quantitative Risk Assessment for a Newly Opened Hospital by AAPM TG-100
J Son1*, M Cho2, S Choi3, K Park4, C Hong5, (1) Yongin Severance Hospital, Yongin, KR (2) Yongin Severance Hospital, Yongin, KR, (3) Yonsei University College of Medicine, Seoul, KR, (4) Yonsei University College of Medicine, Seoul, KR, (5) Yonsei University College of Medicine, Seoul, KR
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PO-GePV-T-208 (Sunday, 7/10/2022) [Eastern Time (GMT-4)]
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Purpose: The aim of this study is to improve the patient safety and to establish the efficient quality management program at a newly opened hospital by the failure mode and effect analysis (FMEA) proposed by TG-100 report.
Methods: A total of 339 patients received radiation therapy in one Linac for a year after opening of our hospital. The errors found at any stages were recorded through an access-based database, and 250 errors were reported by the group. The main source of the scoring guidance came from our health system's patient safety group as well as TG-100. By scoring the risk priority number (RPN), the severity were addressed with protocol changes, checklist supplementation, and standardization. The final FMEA was therefore a combination of the prospective evaluation and the retrospective analysis from an incident improvement system.
Results: 35 faillure modes were identified for pre-existing clinical procedures. The failure mode that recorded the highest RPN for one year after opening of our hospital was a low robustness plan (RPN = 504). As the quarter passed, the number of latent organizational flaws, such as the lack of standardized procedures along with inadequate communication decreased. Through appropriate work education, the causes of inadequate training and human failure occasions also decreased. Through the retrospective failure mode analysis, four additional failure modes were added to the FMEA following the incident analysis.
Conclusion: Risk management with FMEA was very effective for a newly opened hospital. It presented clear standards for work and was able to quantitatively identify vulnerable areas for patient safety in the institution. A further study is to improve the ambiguity of the RPN scoring stages through chart check automation to effectively manage the risk of frequently occurring human failures.
Funding Support, Disclosures, and Conflict of Interest: This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (NRF-2021R1A2C1010900).
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