1277 / 1456
Process map:
Online 3D portal imaging
e.g. 6) Image acquisition:
•
Image field treated, PI software
wasn’t ready yet
•
Additional dose of 3 cGy put
into patient
•
Likelyhood: 3-4
•
Severity: 2-4
•
Detectability: 3
•
RPN=3-4*2-4*3=18-48
•
Recommendations:
Education
Better software