Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety
Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety
复制标题
DOI：
10.1016/j.prro.2017.10.007
复制
发表时间：
2018-03-01
影响因子：
3.3
通讯作者：
Weintraub, Sheri
中科院分区：
文献类型：
--
作者：
Ezzell, Gary;Chera, Bhisham;Weintraub, Sheri
目的：放射肿瘤学事件学习系统（RO-ILS）接收来自全国各地设施的事件报告。这项工作提取了数据中常见的错误路径。这些路径，表示为故障树，证明了需要，和机会，防止这些错误和/或限制其传播到treatment.Methods和材料：截至2016年第三季度，2344事件报告已提交给RO-ILS和审查。共对396份被判定为最高优先级的报告进行了重新审查，并分配了最多3个关键词对事件进行分类。基于关键词分配的模式，数据进一步汇总为导致3种一般错误类型的路径：“批准的治疗计划有问题”、“给予治疗师的错误轮班指示”和“治疗时执行的错误轮班”。“故障树的创建显示了不同的错误在不同的阶段，在治疗过程中联合收割机如何组合成这些一般的错误types.Results：总共有173的396（44%）事件的特点是属于这3个一般错误类型之一。99起事件被定义为“批准的治疗计划有问题”，40起事件被定义为“给予治疗师的错误轮班指示”，34起事件被定义为“治疗时执行的错误轮班”。其中76例（44%）导致治疗不正确。事件由治疗师（n = 76）、物理学家（n = 45）、内科医生（n = 23）、剂量测定师（n = 15）或未识别（n = 9）发现; 5起事件是由于患者询问工作人员而发现的。对于事件类型“有问题的计划批准治疗，”64的99（65%）事件可归因于医生的错误：不正确的目标或剂量pattern.Conclusions：从RO-ILS事件报告中提取的数据表明，在放射肿瘤学传播的所有方式治疗常见的错误途径。需要进一步研究和协调努力，以制定和分享最佳做法，解决这些错误的根源并遏制其传播。(c)2017年美国放射肿瘤学会。爱思唯尔公司出版All rights reserved.
Purpose: The Radiation Oncology Incident Learning System (RO-ILS) receives event reports from facilities across the country. This effort extracted common error pathways seen in the data. These pathways, expressed as fault trees, demonstrate the need for, and opportunities for, preventing these errors and/or limiting their propagation to treatment.Methods and materials: As of the third quarter of 2016, 2344 event reports had been submitted to RO-ILS and reviewed. A total of 396 of the reports judged highest priority were rereviewed and assigned up to 3 keywords to classify events. Based on patterns among the keyword assignments, the data were further aggregated into pathways leading to 3 general error types: "problematic plan approved for treatment," "wrong shift instructions given to therapists," and "wrong shift performed at treatment."Fault trees were created showing how different errors at different stages in the treatment process combine to flow into these general error types.Results: A total of 173 of the 396 (44%) events were characterized as belonging to 1 of these 3 general error types. Ninety-nine events were defined as "problematic plan approved for treatment," 40 as "wrong shift instructions given to therapists," and 34 as "wrong shift performed at treatment." Seventy-six of these events (44%) resulted in incorrectly delivered treatment. Event discovery was by therapists (n = 76), physicists (n = 45), physicians (n = 23), dosimetrists (n = 15), or not identified (n = 9); 5 events were found as a result of the patient questioning the staff. For the event type "problematic plan approved for treatment," 64 of the 99 (65%) events were attributable to physician error: incorrect target or dosing pattern prescribed.Conclusions: Data extracted from RO-ILS event reports demonstrate common error pathways in radiation oncology that propagate all the way to treatment. Additional study and coordination of efforts is needed to develop and share best practices to address the sources of these errors and curtail their propagation. (c) 2017 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.