S2899
RTT- RTT operational practice and workflow innovations
ESTRO 2026
included standardized checklists, redundancy in image and data verification, dual physics plan review, and targeted staff training.
Poster Discussion 29 Application of Failure Mode and Effects Analysis in Gynecological Brachytherapy: Advancing Risk Management for Patient Safety and Treatment Quality Sheng-Fang Huang 1,2 , Ming-Hsien Li 1,3 , Jo-Ting Tsai 1,3 , Chee-Kin Then 1,4 , Chih-Chieh Chang 1 , Chun-Yuan Kuo 1,2 , Li-Jhen Chen 1 , Jang-Chun Lin 1,3 , Yi-Chieh Tsai 1 , Po-Wei Huang 1 , Wei-Kai Chuang 1,5 1 Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan. 2 School of Biomedical Engineering,College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan. 3 Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. 4 Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. 5 Department of Radiation Oncology, Saint Paul’s Hospital, Taoyuan, Taiwan Purpose/Objective: To apply the structured risk analysis framework of AAPM TG-100 to evaluate the workflow of gynecological brachytherapy, identify high-risk failure modes (FMs), and propose risk-based quality management strategies to enhance patient safety. Material/Methods: Following TG-100 methodology, the workflow was mapped into six major process groups: preprocedure, applicator insertion, CT imaging, treatment planning, treatment delivery, and post-treatment procedures. A multidisciplinary team identified potential FMs, assessed occurrence (O), severity (S), and detectability (D) using a 1–10 scale, and calculated risk priority numbers (RPN=O × S × D). FMs with RPN >100 or severity ≥ 8 were considered high risk. The distribution of O, S, and D values as a function of RPN was analyzed to guide prioritization of corrective actions. Results: Figure 1 shows the process map of the workflow of gynecological brachytherapy. Table 1 presents the Identified steps and FMs with average of O, D, S and RPN scores for each process. Table 2 presents the FMs with RPN score over 100 or S value ≥ 8. Among the 28 high-risk FMs identified, four exceeded the RPN threshold of 100, while 15 were characterized by a high severity score (S ≥ 8), highlighting their clinical significance. Figure 2 shows the Distribution of O, S, and D values as a function of RPN score for all potential FMs. These high-impact risks were mainly associated with low detectability or catastrophic consequences. Recommended mitigation strategies
Conclusion: FMEA is an effective method for systematic risk management in gynecological brachytherapy. The findings provide actionable insights to enhance workflow safety, improve treatment quality, and reduce the likelihood of adverse events, supporting patient safety and clinical reliability. References: 1. Huq MS, Fraass BA, Dunscombe PB, et al. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Med Phys. 2016;43:4209.2. Ford E, Conroy L, Dong L, et al. Strategies for effective physics
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