Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California.
Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California.
Int J Radiat Oncol Biol Phys. 2014 Dec 1;90(5):1202-7. doi: 10.1016/j.ijrobp.2014.08.332. Epub 2014 Oct 13.
To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation.
On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment).
During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program.
Incident learning systems are a useful and practical means of improving safety and quality in patient care.
报告在放射肿瘤学临床中使用事件学习系统的情况，并对员工参与情况进行回顾。
2010 年 9 月 24 日，我们科室启动了一个名为放射肿瘤学质量报告系统（ROQRS）的在线实时自愿报告安全问题的系统。我们回顾了该计划从开始到 2013 年 1 月 18 日（2 年 3 个月 25 天）的数据，以评估错误报告（定义为接近错误和不准确治疗的事件）。
在研究期间，有 60168 个外部束放射治疗和 955 个近距离放射治疗的分次。ROQRS 系统中有 298 条记录，其中报告了 108 个错误。有 31 个接近错误和 27 个不准确治疗的事件报告。这些不准确治疗的事件发生在 68 个总治疗分次中（研究期间所治疗分次的 0.11%）。这些不准确治疗的事件中，没有一个导致处方剂量偏差超过 5%。在 ROQRS 中，有 65%的错误记录了解决方案。22%的错误是重复出现的。相当数量的不准确治疗事件是由于在直线加速器上不正确的患者摆位（P<.001）造成的。最初医生没有参与 ROQRS，但在教育项目后有所改善。
事件学习系统是提高患者安全和质量的一种有用且实用的方法。
