Consensus recommendations for incident learning database structures in radiation oncology
Consensus recommendations for incident learning database structures in radiation oncology
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DOI：
10.1118/1.4764914
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发表时间：
2012-12-01
期刊：
影响因子：
3.8
通讯作者：
Dunscombe, P.
中科院分区：
文献类型：
--
作者：
Ford, E. C.;de Los Santos, L. Fong;Dunscombe, P.
目的：事件学习在提高各种行业和医疗学科的质量和安全方面发挥着关键作用。然而，实施一个有效的事件学习系统是复杂的，特别是在放射肿瘤学。目前的一个障碍是缺乏技术标准来指导用户或开发人员。这份报告，由美国医学物理学家协会放射肿瘤学错误预防工作组的倡议的产物，提供了放射肿瘤学事件学习数据库的内容和结构的技术建议。Methods：一个专家小组被召集，并负责在五个关键领域制定共识建议：定义、过程图、严重性量表、因果分类和数据元素。与会专家包括来自北美所有主要放射肿瘤学组织的代表，以及具有二十多年集体经验的公共和内部报告系统的用户和开发人员。考虑到现有的事件学习系统，以及外部agencies.Results的要求制定了建议：共识建议提供的五大主题领域。在过程映射任务中，确定了91个外部射束放射治疗和88个近距离放射治疗的常见步骤。过程图的一个新功能是识别“安全屏障”，也称为关键控制点，这是任何过程步骤，其主要功能是防止错误或错误发生或通过放射治疗工作流程传播。其他建议包括一个10级医疗严重性量表，旨在反映观察到的或估计的伤害，对病人，辐射肿瘤的具体根本原因表，以促进和规范的根本原因分析，并建议数据元素和结构，以帮助开发电子数据库。还提出了任何报告system.Conclusions的关键功能要求的列表：事件学习被认为是一个宝贵的工具，提高治疗的质量和安全性。本报告中的共识建议旨在促进在个体诊所以及更广泛的国家和国际范围内实施此类系统。(C)2012年美国医学物理学家协会。[http：//dx.doi.org/10.1118/1.4764914]
Purpose: Incident learning plays a key role in improving quality and safety in a wide range of industries and medical disciplines. However, implementing an effective incident learning system is complex, especially in radiation oncology. One current barrier is the lack of technical standards to guide users or developers. This report, the product of an initiative by the Work Group on Prevention of Errors in Radiation Oncology of the American Association of Physicists in Medicine, provides technical recommendations for the content and structure of incident learning databases in radiation oncology.Methods: A panel of experts was assembled and tasked with developing consensus recommendations in five key areas: definitions, process maps, severity scales, causality taxonomy, and data elements. Experts included representatives from all major North American radiation oncology organizations as well as users and developers of public and in-house reporting systems with over two decades of collective experience. Recommendations were developed that take into account existing incident learning systems as well as the requirements of outside agencies.Results: Consensus recommendations are provided for the five major topic areas. In the process mapping task, 91 common steps were identified for external beam radiation therapy and 88 in brachytherapy. A novel feature of the process maps is the identification of "safety barriers," also known as critical control points, which are any process steps whose primary function is to prevent errors or mistakes from occurring or propagating through the radiotherapy workflow. Other recommendations include a ten-level medical severity scale designed to reflect the observed or estimated harm to a patient, a radiation oncology-specific root causes table to facilitate and regularize root-cause analyses, and recommendations for data elements and structures to aid in development of electronic databases. Also presented is a list of key functional requirements of any reporting system.Conclusions: Incident learning is recognized as an invaluable tool for improving the quality and safety of treatments. The consensus recommendations in this report are intended to facilitate the implementation of such systems within individual clinics as well as on broader national and international scales. (C) 2012 American Association of Physicists in Medicine. [http://dx.doi.org/10.1118/1.4764914]