Prostate Brachytherapy UK & Ireland 11-12 June 2026

Poster Presentation – Abstracts Archive

UK & Ireland Prostate Brachytherapy Conference 2013

Abstract number 5

The Use of Failure Mode Effect Analysis to Enhance Quality in Prostate Seed Brachytherapy

Colin Kelly
St Luke’s Radiation Oncology Network, Dublin, Ireland
Brian Langan
St Luke’s Radiation Oncology Network, Dublin, Ireland
Christopher Walker
St Luke’s Radiation Oncology Network, Dublin, Ireland
Brian O’Neill
St Luke’s Radiation Oncology Network, Dublin, Ireland
Gerard McVey
St Luke’s Radiation Oncology Network, Dublin, Ireland

Aims/Introduction: The delivery of high quality prostate brachytherapy is a complex task combining sophisticated hardware and software technologies with crucial human interventions and decision making across the multidisciplinary team.  Ensuring that the potential benefit to the patient is maximised and that the risk of harm, by failures in the process, is reduced is the responsibility of the caregivers.  In this work the use of Failure Mode Effect Analysis (FMEA) is described for the proactive identification of potential risk for patients undergoing I-125 permanent seed brachytherapy at a single institute. 

Materials/Methods: FMEA was conducted by applying four main steps to the brachytherapy process as follows:

  1. Process Mapping: a detailed map involving the main nodes of activity and identifying associated inputs, outputs, tasks and check procedures was developed.
  2. Catalogue of Failure Modes (FM): frontline staff were interviewed and asked to identify potential failures in the system.
  3. Analysis of FM: Using actuarial methods the identified FMs were allocated a Risk Priority Number (RPN) defined as the product of indices associated with Severity,   Occurrence and Detection.
  4. Process redesign: Proactive re-engineering of the treatment process to strengthen defences against the pre-identified FMs.

Results: A total of 43 FMs were identified of which 12 were considered to have RPNs sufficiently high to necessitate process redesign. The results included the commissioning of automatic contouring software, the development of an independent check programme for dose calculation and the design of a QA phantom for US image quality. 

Conclusions: FMEA is a tool that was developed first by the automobile industry. Its use in radiotherapy has been proposed by IAEA (ICRP 112) and it is currently the subject of a major project being carried out by the American Association of Physicists in Medicine (AAPM) (TG-100). This study demonstrates its effectiveness as a tool for enhancing quality and reducing risk in prostate brachytherapy.