ASMR 2016

Recommended Actions

Risk Priori ty Num ber (RPN )

Sever ity (1- 10)

Likelihood of Detection (1-10)

Likeliho od of O curre nce (1-10)

Potential Failure Eff cts

Potential Failure Causes

Potential Failure Mode

Steps in the Proce ss

Feedback session

1

select wrong patient wrong data to system

No check

Treating with different iso Wrong treatment vol Useless imaging dose

1

3

10 30 Compare ID

Automatic check ID

2

Retreat

5

3

8

120 Laballing/JCI/archivi ng/educatiion

3

2

1

2

4

Free reading glasses

Wrong selection images

inverse direction of image

4 5 6 7 8 9

Staff change/

Wrong isocenter

3

1

5-9 15-27 Check ID, brirthdate

Image wrong patient

importing the wrong image

Human error

Wrong treatment

3

4

7

84 Double check,

10 11