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Feedback session
Steps
in the
Proce
ss
Potential
Failure
Mode
Potential
Failure
Causes
Potential
Failure
Eff cts
Likeliho
od of
O curre
nce
(1-10)
Likelihood
of
Detection
(1-10)
Sever
ity
(1-
10)
Risk
Priori
ty
Num
ber
(RPN
)
Recommended
Actions
1
select wrong
patient
No check
Treating with
different iso
1
3
10 30 Compare ID
Automatic check ID
2
wrong data to
system
Retreat
Wrong
treatment vol
5
3
8
120 Laballing/JCI/archivi
ng/educatiion
3
inverse
direction of
image
Wrong
selection
images
Useless
imaging dose
2
1
2
4
Free reading glasses
4
5
Image wrong
patient
Staff change/
Wrong
isocenter
3
1
5-9 15-27 Check ID, brirthdate
6
7
importing the
wrong image
Human error
Wrong
treatment
3
4
7
84 Double check,
8
9
10
11