Quality Management 2017

Proactive Risk Analysis

Select one process

Simulation

Divide the process subprocesses or steps

Select another system or process and repeat

Describe each of the steps/equipment

Patient immobilization: head mask

Select one subprocess

The mask is not well done (does not adapt well)

Define the failure mode that can have that step or subprocess

Select another step or subprocess and repeat

Temperature of the bath Two persons needed only one present

Examine the causes of the failure mode

Select another failure mode and repeat the process

Different position between planning and treatment delivery: Underdosing PTV

Evaluate the consequences caused by the failure mode

Propose actions

Estimate Risk

Evaluate the defences that are in place so that in case of failure the security is not affected

Verification of immobilisation first day Imaging