The management of radiation treatment error through incident learning
The management of radiation treatment error through incident learning
复制标题
通过事件学习管理放射治疗错误
DOI：
10.1016/j.radonc.2010.03.022
复制
发表时间：
2010-06-01
影响因子：
5.7
通讯作者：
Grimard, Laval
中科院分区：
文献类型：
--
作者：
Clark, Brenda G.;Brown, Robert J.;Grimard, Laval
目的：评估事件学习系统在放射治疗差错管理中的有效性。材料和方法：我们报告了一个为放射治疗定制的事件学习系统实施方案，其中报告、调查和学习任何“导致或可能对人员或设备造成不利影响的不想要的或意外的系统行为改变”。因此，这个系统捕捉到了险些发生的(潜在的)和实际发生的事件。根据严重程度、类型和来源对事件进行分类。结果：我们的分析跨度为3年，平均每周累积11.6起事件。我们发现，与第一年(P<；0.001)相比，第二年和第三年的实际事件分别减少了28%和47%，这归因于对报告事件的分析促使了许多干预措施。我们还看到，由于引入了直接治疗参数转移和电子成像(P<；0.001)，治疗单位发生的事故也有了类似的显著减少。结论：事件学习系统的实施帮助我们建立了一个公正的环境，在这个环境中，所有工作人员都报告了偏离正常系统行为的情况，从而产生了证据，以启动安全改进。(C)2010爱思唯尔爱尔兰有限公司。保留所有权利。放射治疗与肿瘤学95(2010)344-349
Purpose: To assess efficacy of an incident learning system in the management of error in radiation treatment.Materials and methods: We report an incident learning system implementation customized for radiation therapy where any "unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment" is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin.Results: Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p < 0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p < 0.001).Conclusions: Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements. (C) 2010 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 95 (2010) 344-349