AAPM Spring Clinical Meeting. Fault Tree Analysis. Peter Dunscombe, PhD, FCCPM, FAAPM, FCOMP Professor Emeritus University of Calgary
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1 AAPM Spring Clinical Meeting Fault Tree Analysis Peter Dunscombe, PhD, FCCPM, FAAPM, FCOMP Professor Emeritus University of Calgary
2 AAPM Spring Clinical Meeting Fault Tree Analysis
3 AAPM Spring Clinical Meeting Fault Tree Analysis
4 Disclosure Peter Dunscombe is a Member of TreatSafely, LLC treatsafely.org
5 Objectives To appreciate the relationship between Fault Tree Analysis and Failure Modes and Effects Analysis. To explore the similarities and differences between Fault Tree Analysis and Root Cause Analysis. To look at the practical uses of Fault Tree Analysis.
6 The AAPM s Task Group 100 Process Mapping helps us to understand the details of the patient s clinical pathway. Failure Modes and Effects Analysis helps us to prioritize failure modes for further analysis. Fault Tree Analysis helps us to identify: possible systemic program weaknesses where to put barriers and checks.
7 Purpose of a Fault Tree Analysis To make the (radiotherapy) system safer through using postulated failure modes, tracing the failure pathways back and, on the basis of the FTA, Identifying possible systemic program weaknesses. Placing barriers and checks (QA and QC) Error in data Error in QC Error in data input Error in Calculated value for patient Error in calculation Error in QA Error in QC Error in Calculation algorithm Error in QC Error in prescription Error in QC
8 Fault Tree Analysis Fault Tree Analyses are extensively used in high risk, high reliability industries such as the chemical, nuclear and aviation industries.
9 FTA in the context of FMEA Step # Major Processes Step Potential Failure Modes Potential Causes of Failure Potential Effects of Failure O S D RPN Examples of Causes and Failures Day 1 Treatment Treatment delivered LINAC hardware failures/wrong dose per MU; MLC leaf motions inaccurate, flatness/symmetry, energy, etc Poor hardware design Poor hardware maintenance. Inadequate physics QA process Wrong dose Wrong dose distribution Wrong location Wrong volume Wrong to very wrong dose affecting all patients treated on machine (or with affected beams) until problem is found and corrected RTP Anatomy Delineate GTV/CTV (MD) and other structures for planning Contouring errors: wrong organ, wrong site, wrong expansions User error Inattention, lack of time, failure to review own work Very wrong dose distributions Very wrong volumes Wrong target volume contour leads directly to very wrong dose distributions and volumes. Low detectability assumes only review is by physicist and MD Other pretreatment imaging for CTV localization Images correctly interpreted Incorrect interpretation of tumor or normal tissue. User not familiar with modality or inadequately trained. Poor interdisciplinary communication Wrong volume
10 FTA in the context of FMEA Step # Major Processes Step Potential Failure Modes Potential Causes of Failure Potential Effects of Failure O S D RPN Examples of Causes and Failures Day 1 Treatment Treatment delivered LINAC hardware failures/wrong dose per MU; MLC leaf motions inaccurate, flatness/symmetry, energy, etc Poor hardware design Poor hardware maintenance. Inadequate physics QA process Wrong dose Wrong dose distribution Wrong location Wrong volume Wrong to very wrong dose affecting all patients treated on machine (or with affected beams) until problem is found and corrected RTP Anatomy Delineate GTV/CTV (MD) and other structures for planning Contouring errors: wrong organ, wrong site, wrong expansions User error Inattention, lack of time, failure to review own work Very wrong dose distributions Very wrong volumes Wrong target volume contour leads directly to very wrong dose distributions and volumes. Low detectability assumes only review is by physicist and MD Other pretreatment imaging for CTV localization Images correctly interpreted Incorrect interpretation of tumor or normal tissue. User not familiar with modality or inadequately trained. Poor interdisciplinary communication Wrong volume
11 Root Cause Analysis (RCA)
12 Fault Tree Analysis (FTA)
13 FTA in the context of RCA Look similar?
14 FTA in the context of RCA A Fault Tree Analysis can be regarded as a hypothetical Root Cause Analysis. An actual event starts an RCA Postulated failure modes are used to start an FTA. However, in both, the failure pathway is traced back. Postulated failure modes can be imported from a Failure Modes and Effects Analysis.
15 Performing a Fault Tree Analysis A Fault Tree Analysis is normally carried out by a small team: Leader knowledge of FTA and subject area of review Facilitator expertise in FTA Content experts knowledge of subject area of review and preferably multidisciplinary in our environment.
16 Engineering Fault Tree
17 Example: Probabilistic Fault Tree (Thomadsen) Thomadsen et al. IJROBP 2003 (57) 1496 IJROBP 2003 (57) 1498
18 Interesting quote from Thomadsen s paper In industries such as nuclear power, where probabilistic risk assessment originated, most failures occur only when several systems fail concurrently, and the combination of probabilities becomes important. Most medical events, although they have several root causes and concurrent unusual situations, fail along a single branch of the fault tree Thomadsen et al. IJROBP 2003 (57) 1496 IJROBP 2003 (57) 1498
19 Prescient observation by Thomadsen Errors often follow violations in protocols, particularly failures to perform verification procedures, and indicators that things are not correct are often present yet ignored during events. Radiation Offers New Cures, and Ways to Do Harm By WALT BOGDANICH Thomadsen et al. IJROBP 2003 (57) 1496 New York Incident? IJROBP 2003 (57) 1498
20 Fault Tree Analysis FMEA input Failure Modes and Effects Analysis helps to prioritize failure modes for further analysis. Step # Major Processes Step Potential Failure Modes Potential Causes of Failure Potential Effects of Failure O S D RPN Examples of Causes and Failures Day 1 Treatment Treatment delivered LINAC hardware failures/wrong dose per MU; MLC leaf motions inaccurate, flatness/symmetry, energy, etc Poor hardware design Poor hardware maintenance. Inadequate physics QA process Wrong dose Wrong dose distribution Wrong location Wrong volume Wrong to very wrong dose affecting all patients treated on machine (or with affected beams) until problem is found and corrected RTP Anatomy Delineate GTV/CTV (MD) and other structures for planning Contouring errors: wrong organ, wrong site, wrong expansions User error Inattention, lack of time, failure to review own work Very wrong dose distributions Very wrong volumes Wrong target volume contour leads directly to very wrong dose distributions and volumes. Low detectability assumes only review is by physicist and MD Other pretreatment imaging for CTV localization Images correctly interpreted Incorrect interpretation of tumor or normal tissue. User not familiar with modality or inadequately trained. Poor interdisciplinary communication Wrong volume
21 Fault Tree Analysis systemic program issues Fault Tree Analysis helps to identify possible systemic program weaknesses
22 Fault Tree Analysis - safety barriers and checks Fault Tree Analysis helps to identify where to put barriers and checks. Error in data Error in QC Error in data input Error in Calculated value for patient Error in calculation Error in QA Error in QC Error in Calculation algorithm Error in QC Error in prescription Error in QC
23 Fault Tree Software - Alf
24 Quality Management - Bruce The prevention of events can be by: Eliminating progenitor causes, OR By interrupting the propagation.
25 Fault Tree Analysis Exercise 1. Choose 1 of the 2 TG 100 Failure Modes. 1. Develop a Fault Tree for this Failure Mode. 1. Make sure each branch ends (on the right) on a progenitor cause/ contributing factor or latent condition. 1. Make sure the (right) branch ends are actionable. 2. Do not include safety barriers and checks at this time. We ll do that later.
26 Fault Tree Analysis Exercise You should generate something like this
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