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Analyze the separate steps
•
Identify failure modes in process
•
3 factors associated with each mode:
!
Probability
:
"
Likelihood of occurrence
"
Event happening to 1% of patients (score 1), all (score 10)
!
Detectability
:
"
How likely are we to catch the event?
"
Easy catch (score 1), almost impossible to detect (score 10)
!
Severity
:
"
What is the consequence if it reaches the patient?
"
Causes discomfort or inconvenience (score 1), dose difference >
20%, injury or death (score 10).
•
Calculate Risk Probability Number (RPN)
SBRT 2015 - D. Verellen
33