Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy

Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.

[1]  Steve B. Jiang,et al.  GPU-based high-performance computing for radiation therapy , 2014, Physics in medicine and biology.

[2]  Barrett Caldwell,et al.  Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques. , 2003, International journal of radiation oncology, biology, physics.

[3]  Eric C Ford,et al.  Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. , 2009, International journal of radiation oncology, biology, physics.

[4]  Celso Marcelo Franklin Lapa,et al.  Fuzzy inference to risk assessment on nuclear engineering systems , 2007, Appl. Soft Comput..

[5]  Marcello Braglia,et al.  Fuzzy criticality assessment model for failure modes and effects analysis , 2003 .

[6]  Dyadem Press Guidelines for Failure Mode and Effects Analysis (FMEA), for Automotive, Aerospace, and General Manufacturing Industries , 2003 .

[7]  Loon Ching Tang,et al.  Fuzzy assessment of FMEA for engine systems , 2002, Reliab. Eng. Syst. Saf..

[8]  Chee Peng Lim,et al.  Fuzzy FMEA with a guided rules reduction system for prioritization of failures , 2006 .

[9]  Joseph M. Derosier,et al.  Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. , 2002, The Joint Commission journal on quality improvement.

[10]  Paul Keall,et al.  Failure mode and effect analysis-based quality assurance for dynamic MLC tracking systems. , 2010, Medical physics.

[11]  Jhareswar Maiti,et al.  Risk analysis using FMEA: Fuzzy similarity value and possibility theory based approach , 2014, Expert Syst. Appl..

[12]  F Castiglia,et al.  Risk analysis using fuzzy set theory of the accidental exposure of medical staff during brachytherapy procedures , 2010, Journal of radiological protection : official journal of the Society for Radiological Protection.

[13]  Ping Li,et al.  Failure mode and effects analysis using intuitionistic fuzzy hybrid weighted Euclidean distance operator , 2014, Int. J. Syst. Sci..

[14]  Jean-Pierre Bissonnette,et al.  Error in the delivery of radiation therapy: results of a quality assurance review. , 2005, International journal of radiation oncology, biology, physics.

[15]  B. Fuchs,et al.  Failure mode and effects analysis application to critical care medicine. , 2005, Critical care clinics.

[16]  Harald Paganetti,et al.  Relative biological effectiveness (RBE) values for proton beam therapy. , 2002, International journal of radiation oncology, biology, physics.

[17]  Lotfi A. Zadeh,et al.  The Calculus of Fuzzy If/Then Rules , 1992, Fuzzy Days.

[18]  Jian-Bo Yang,et al.  Risk evaluation in failure mode and effects analysis using fuzzy weighted geometric mean , 2009, Expert Syst. Appl..

[19]  Jin Wang,et al.  Fuzzy Rule-Based Bayesian Reasoning Approach for Prioritization of Failures in FMEA , 2008, IEEE Transactions on Reliability.

[20]  M. Scorsetti,et al.  Applying failure mode effects and criticality analysis in radiotherapy: lessons learned and perspectives of enhancement. , 2010, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[21]  Dinesh Kumar,et al.  Systematic failure mode effect analysis (FMEA) using fuzzy linguistic modelling , 2005 .

[22]  Benedick A Fraass,et al.  A method for evaluating quality assurance needs in radiation therapy. , 2008, International journal of radiation oncology, biology, physics.

[23]  Ebrahim H. Mamdani,et al.  An Experiment in Linguistic Synthesis with a Fuzzy Logic Controller , 1999, Int. J. Hum. Comput. Stud..

[24]  J. B. Bowles,et al.  Fuzzy logic prioritization of failures in a system failure mode, effects and criticality analysis , 1995 .

[25]  Mesut Kumru,et al.  Fuzzy FMEA application to improve purchasing process in a public hospital , 2013, Appl. Soft Comput..

[26]  Gavriel Salvendy,et al.  Handbook of Human Factors and Ergonomics , 2005 .

[27]  Jin Wang,et al.  Modified failure mode and effects analysis using approximate reasoning , 2003, Reliab. Eng. Syst. Saf..

[28]  Jonathan B Kruskal,et al.  Application of failure mode and effect analysis in a radiology department. , 2011, Radiographics : a review publication of the Radiological Society of North America, Inc.

[29]  Tzung-Pei Hong,et al.  Induction of fuzzy rules and membership functions from training examples , 1996, Fuzzy Sets Syst..

[30]  Hu-Chen Liu,et al.  Failure mode and effects analysis using fuzzy evidential reasoning approach and grey theory , 2011, Expert Syst. Appl..

[31]  J. Valentin Preface, Main Points, Introduction, Chapters 2 and 3 , 2005 .

[32]  Cengiz Kahraman,et al.  Healthcare Failure Mode and Effects Analysis Under Fuzziness , 2013 .

[33]  S. Richardson A 2-year review of recent Nuclear Regulatory Commission events: What errors occur in the modern brachytherapy era? , 2012, Practical radiation oncology.

[34]  Marcello Braglia,et al.  MAFMA: multi‐attribute failure mode analysis , 2000 .

[35]  Jian-Bo Yang,et al.  Failure mode and effects analysis using a group-based evidential reasoning approach , 2009, Comput. Oper. Res..

[36]  Hu-Chen Liu,et al.  Fuzzy Failure Mode and Effects Analysis Using Fuzzy Evidential Reasoning and Belief Rule-Based Methodology , 2013, IEEE Transactions on Reliability.

[37]  Nan Liu,et al.  Risk evaluation in failure mode and effects analysis with extended VIKOR method under fuzzy environment , 2012, Expert Syst. Appl..

[38]  Lotfi A. Zadeh,et al.  The concept of a linguistic variable and its application to approximate reasoning-III , 1975, Inf. Sci..

[39]  Mariarosa Giardina,et al.  Analysis of operator human errors in hydrogen refuelling stations: Comparison between human rate assessment techniques , 2013 .

[40]  Ebrahim Mamdani,et al.  Applications of fuzzy algorithms for control of a simple dynamic plant , 1974 .

[41]  David de la Fuente,et al.  A decision support system for applying failure mode and effects analysis , 2002 .

[42]  R. Vetter ICRP Publication 103, The Recommendations of the International Commission on Radiological Protection , 2008 .

[43]  B. Franklin,et al.  Is Failure Mode and Effect Analysis Reliable? , 2009, Journal of patient safety.

[44]  J. Moubray Reliability-centred maintenance , 1995 .

[45]  Pascale Carayon,et al.  Handbook of human factors and ergonomics in health care and patient safety , 2006 .

[46]  F Castiglia,et al.  FUZZY RISK ANALYSIS OF A MODERN &ggr;-RAY INDUSTRIAL IRRADIATOR , 2011, Health physics.

[47]  Nazirah Ramli,et al.  A COMPARATIVE ANALYSIS OF CENTROID METHODS IN RANKING FUZZY NUMBERS , 2009 .

[48]  Hisao Ishibuchi,et al.  Effect of rule weights in fuzzy rule-based classification systems , 2001, IEEE Trans. Fuzzy Syst..

[49]  J. Williamson,et al.  High dose-rate brachytherapy treatment delivery: report of the AAPM Radiation Therapy Committee Task Group No. 59. , 1998, Medical physics.

[50]  Nan Liu,et al.  Risk evaluation approaches in failure mode and effects analysis: A literature review , 2013, Expert Syst. Appl..

[51]  Sanjay Kumar Chaturvedi,et al.  Criticality Assessment Models for Failure Mode Effects and Criticality Analysis Using Fuzzy Logic , 2011, IEEE Transactions on Reliability.