ABSTRACT
A failure mode is essentially anything that can go wrong in the process of care. Examples include a wrong treatment location or a miscommunication about the start of chemotherapy. Failure mode and effect analysis (FMEA) consists of identifying these potential failure modes and then assigning each of them a numerical score for risk. The goal of FMEA analysis is to understand and identify risk in the complex process of care. Incident learning is recommended by national and international associations including American Association of Radiation Oncology (ASTRO) in the Safety Is No Accident Report. Of note is the Radiation Oncology Incident Learning System, a national system sponsored by ASTRO and AAPM for practices in the United States. This system, launched in 2014, provides a platform for shared learning in a protective and non-punitive environment. This is conducted under the auspices of a Patient Safety Organization which is an entity protected under United States law.
