Failure mode and effect analysis (FMEA) of radiotherapy

2020 ◽  
Vol 10 (4) ◽  
pp. 1-22
Author(s):  
Rajaram Govindarajan ◽  
Mohammed Laeequddin
Keyword(s):  
Health Care ◽  
Quality Management ◽  
Ethical Dilemma ◽  
Failure Modes ◽  
Root Cause Analysis ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause ◽  
Error Proofing

Learning outcomes Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues. Case overview/synopsis Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected. Complexity academic level MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics. Supplementary materials Teaching Notes are available for educators only. Subject code CSS 9: Operations and Logistics.

A proposed hybrid root cause analysis technique for quality management

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Dharyll Prince Abellana
Keyword(s):  
Quality Management ◽  
Structural Model ◽  
Group Discussion ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause ◽  
Analysis Technique ◽  
Proposed Model ◽  
Cause And Effect Diagram

PurposeThis paper attempts to develop a hybrid cause and effect diagram (CED) and interpretative structural model (ISM) for root cause analysis in quality management. The proposed model overcomes the weakness of the CED in reliably articulating hierarchical cause–effect Relationships.Design/methodology/approachA focus group discussion (FGD) among quality experts in the case company to establish relationships between the determined causes.FindingsThe hybridization of the CED and ISM allowed the causes to be ordered more clearly to determine potential root causes as well as presenting these causes more comprehensively.Originality/valueThe paper has been one of the very few attempts to improve the CED approach. As such, this paper employs the ability of the ISM to order concepts in a hierarchical structure, which is useful in determining root causes.

Different Failure Modes of Non-Metallic Pipelines at Connections

2014 ◽  
Author(s):  
Alex Tatarov ◽  
Frank Gareau
Keyword(s):  
Failure Modes ◽  
Root Cause Analysis ◽  
Case Histories ◽  
Actual Case ◽  
Cause Analysis ◽  
Root Cause ◽  
Pipeline Failures

The article provides an overview of different modes of failures in composite pipeline connections. Non-metallic spoolable (SCP) and reinforced thermoplastic pipelines (RTP) of different makes will be addressed. The article is based on actual case histories of pipeline failures (root cause analysis). Numerous factors contributing to failures and recommendations are discussed.

scholarly journals To err is human: medication patient safety in aged care, a case study

2018 ◽  
Vol 19 (2) ◽  
pp. 126-134
Author(s):  
Julia Gilbert ◽  
Jeong-ah Kim
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Management ◽  
Care Facility ◽  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

scholarly journals Risk Analysis in the Automotive Industry

2020 ◽  
Author(s):  
Annamária Koncz ◽  
László Pokorádi ◽  
Zsolt Csaba Johanyák
Keyword(s):  
Risk Analysis ◽  
Failure Mode ◽  
Automotive Industry ◽  
Root Cause Analysis ◽  
Automotive Sector ◽  
Analysis Method ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Safety And Reliability

The automotive industry is one of the most dynamically growing fields of the manufacturingarea. Besides this, it has very strict rules concerning safety and reliability. In our work, our aim is to point out the importance of the automotive industry (based on statistics) and the rules in connection with risk and root cause analysis. The most important risk analysis method is the Failure Mode and Effect Analysis (FMEA). According to standards and OEM regulations, FMEA is obligatory in the automotive sector. In our study, we summarise the area of FMEA usage, its types and process steps.

scholarly journals PEMODELAN PENINGKATAN KEHANDALAN DENGAN METODE ROOT CAUSE ANALYSIS DAN FMEA PADA PERUSAHAAN PEMBANGKIT LISTRIK

2017 ◽  
Vol 6 (1) ◽  
Author(s):  
Ferry Anggita Erdianto
Keyword(s):  
Performance Appraisal ◽  
Preventive Maintenance ◽  
System Analysis ◽  
Electrical Energy ◽  
Root Cause Analysis ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Load Demand ◽  
Energy Reliability

<p>XYZ is a company engaged in the generation of electrical energy. Reliability for power<br />generation companies is very vital for the company's performance appraisal is based on the readiness<br />of the unit to generate electricity load demand PLN (State Electricity Company). To support the<br />reliability of the company has designed a system that is based on the reliability maintenance (RCM).<br />RCM application at PT XYZ is dominated by mostly preventive maintenance based on time and baseline.<br />Meanwhile failures still occur marked by numerous corrective maintenance that still occur on critical<br />equipment, causing derating production unit. Besides the efficiency of preventive maintenance is also<br />doubtful, the amount of PM task that has become a waste of maintenance costs. The pattern of effective<br />maintenance necessary to minimize disturbance.<br />As a baseline, the analysis Root Cause Analysis is required to determine the priority<br />maintenance. After that increase reliability by using Failure Mode and Effect Analysis (FMEA) was<br />conducted with a focus on the criteria of occurence, severity, and detection to determine the Risk<br />Priority Number (RPN). To enhance decision-making systems have used system analysis history data<br />interference as well as MTBF and MTTR. Result of the merger of these methods are known to determine<br />the behavior maintenance task-a task that really affect the reliability of the unit.</p>

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