S2900
RTT- RTT operational practice and workflow innovations
ESTRO 2026
plan and chart review in radiation therapy: Report of AAPM Task Group 275. Med Phys. 2020;47:e236-e72.3. Huq MS, Fraass BA, Dunscombe PB, et al. A method for evaluating quality assurance needs in radiation therapy. Int J Radiat Oncol Biol Phys. 2008;71:S170-3. Keywords: patient safety, FMEA, workflow Digital Poster 80 Comparative Multimodal FMEA-Based Risk Evaluation in Gynecological Brachytherapy Planning Process under DGMP 28 Guidelines Sheng-Fang Huang 1,2 , 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 , Wei-Kai Chuang 1,5 , Ming-Hsien Li 1,3 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 improve patient safety and workflow reliability in gynecological brachytherapy planning by prioritizing failure modes (FMs) using three FMEA-based criticality methods under DGMP No. 28 guidelines: risk priority number (RPN), risk matrix (RM), and action priority (AP). The objective is to assess the consistency and clinical relevance of these methods in guiding risk stratification and corrective actions. Material/Methods: Figure 1 illustrates the brachytherapy planning workflow, segmented into discrete subprocesses. In total, 41 FMs were catalogued for further analysis. Each FM was scored for severity (S), occurrence (O), detectability (D) and net occurrence (NO) according to the ranking system detailed in Table 1. We applied three criticality FMEA methods under DGMP No. 28 guidelines:• Risk Priority Number (RPN): Calculated as the product S × O × D for each FM and rank three risk classes (acceptable, tolerable, unacceptable)• Risk Matrix (RM): Mapped S against NO to assign FMs into three risk levels (low, medium, high).• Action Priority (AP): Assigned each FM to one of three action levels based on S, D, and O, following the DGMP- recommended AP decision table.The results were compared to assess concordance in risk stratification and to identify discrepancies that may influence clinical decision-making.
Results: Table 2 shows the risk categories for the gynecological brachytherapy planning workflow using three FMEA criticality methods. The three methods demonstrated partial overlap in identifying high-risk FMs. Key hazards such as incorrect CTV definition (RPN=108), contouring errors (RPN=90), and wrong catheter index (RPN=81) were consistently classified as high priority across all methods. The RM method provided a more intuitive visualization of risk categories but lacked the granularity of AP in guiding specific interventions. AP was particularly effective in highlighting workflow vulnerabilities stemming from inadequate training, lack of standardization, and communication gaps— factors that were underrepresented in RPN-based analysis. Comparison across methods reveals that the RM and AP approaches emphasize follow-up on medium and high risk failure modes, whereas the RPN method tends to group the majority of modes under tolerable classifications. This disparity highlights how choice of criticality metric under DGMP 28 guidelines can significantly influence risk categorization and subsequent decision-making.
Made with FlippingBook - Share PDF online