Question

You are supervising a clinic that does radiation treatment for patients with cancer. Once the oncologist determines the correct dosage and the correct path, a technologist follows the MD's directions and provides the treatment to the patient. A major danger in providing this treatment is that the technologist will give the wrong dosage. If too high of a dosage is given the patient can be severely burned.

You have observed the technologist work and you have noticed that they are very diligent, but as the day goes on they make more mistakes and have to check the settings more times and make more corrections. Usually they find their mistake before giving the dosage to the patient, but there are occasional burns to patients. The process consists of the technologist seating the patient (position depends on tumor location) and then looking once again at the oncologist's prescribed dosage.

Describe how you would study (gather data and analyze it) this process and the type of poka yoke you could incorporate into it.

Answer 1

We would study (gather data and analyze it) this process and the type of poka yoke we could incorporate into it as below

Process study: We would like to understand the process and its complete flow so that we can review the process scope and they way technologist apply the dosage to the patient based on the oncologist’s advice and recommendations.

We would like to capture the process data and study the data and anylyze the process data suitably to review the wrong dosage treatment to patients. We will analyze number of caes are performed per day/ week / month/ Then the number of wrong dosage issues reported per day/week/month. Then we would like to review the timing of the wrong dosage given to the patients by the technologists. We would like to review any pattern in the time of dosage of all the wrong dosage issues. We will also like to review the patient’s dosage category relation among the wrong dosages given. Thus we would like to review if any timing issues, or dosage issue, particular disease issue, crowd issue, communication issue, disciplinary issue, human error issue etc. Thus based on the data analysis, we would like to come-out with the key causes that are resulting in the wrong dosage to the patients.  

We will review all the wrong dosage issues reported in last month or couple of months, and try to see if we can find any pattern that we can see from the data analysis.

We will like to review the recent good number of correct dosage cases and try to analyze any pattern if we can figure out that is not present in the wrong dosage cases.

Type of Poka Yoka:

• The radiation machine needs to be set and controlled at maximum limit, that beyond this limit the dosage cannot be given to the patient and will not results in burning impact to the patients. If the dosage limits to be increase beyond this limit, the technologist needs to consult to the oncologist and seek approval for the same.

• The another prevention method is that the oncologist needs to give a card to the patient that mentions the dosage for the patient and same card need to be used by the technologist to give the dosage treatment to the patient. The card needs to be attached with the report of dosage so that technologist can be sure for the given treatment.