Keywords:
MR physics, Cardiac, MR, Education, Safety
Authors:
P. Gilligan, P. Cooper, C. Nolan, J. Bisset, C. McEntee, S. Maguire, B. Emerson, J. Galvin, J. G. Murray; Dublin/IE
DOI:
10.1594/ecr2018/C-0969
Methods and materials
A multi-disciplinary team was set up consisting of radiographers,
cardiac physiologists,
cardiologists,
radiologist,
research clinician,
and members of the hospital quality team.
Each step in the current process was mapped (Figure 3) and possible failure modes and effects identified.
Each failure mode was attributed a Risk Priority Number (RPN) which is quantified by incorporating the mode’s likelihood of occurrence(O),
likelihood of detection(D) and the severity of impact(S).
We calculated each failure mode’s RPN by multiplying the 3 numbers(S,
O & D) together to achieve a number between 1 and 1000. Actions were taken to eliminate or minimise failures,
starting with those of highest priority (Figure 4).
A new process map (Figure 5) was developed to reflect measures taken to reduce risk. A repeat failure mode effect analysis was carried out a number of months later and the residual overall RPN and the residual high priority risks were evaluated by the team (Figure 6).
The findings were communicated 1) as part of education sessions locally,
2) to the hospital via the quality department and 3) via national meetings and 4) copies of the FMEA were forwarded to the national regulatory agency. Ongoing monitoring of the process is evaluated through incident reporting and the multi-disciplinary team.