Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
Pract Radiat Oncol. 2019 Nov;9(6):465-478. doi: 10.1016/j.prro.2019.06.022. Epub 2019 Jul 16.
Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust methodology for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs.
The method proposed for performing Bowtie Analysis (BTA) was based on training and recommendations from practitioners in the field of Human Factors and Ergonomics practice. Multidisciplinary meetings to iteratively develop BTA focused on incorrect site setup instructions was conducted.
From November 2015 to February 2017, we had 12 reported incidents related to site setup notes that could have led to site setup errors. Based on this data, we conducted five BTA analyses related to incorrect site setup instructions. None of the individual controls within our QA program designed to check for potential errors with site setup instructions met the level of robustness to be classified as key safeguards or barriers.
The relatively low number of incidents causing patient harm has led us to typically assume that we have sufficient and effective controls in place to prevent serious human errors from leading to severe patient consequences. Based on our BTA, we question how well we truly understand the details of our individual controls. To meet the level of safety achieved by high reliability organizations (HROs), we need to better ensure that our controls are as reliable and robust as we assume.
确保放射治疗（RT）中的安全性至关重要。为了进一步支持和加强患者安全工作，本研究旨在测试和完善一种强大的方法，用于分析在 RT 质量保证（QA）计划中击败个人控制的人为错误。
拟议的执行 Bowtie 分析（BTA）的方法基于人为因素和人体工程学实践领域从业者的培训和建议。进行了多次多学科会议，以迭代方式开发专注于不正确站点设置说明的 BTA。
从 2015 年 11 月至 2017 年 2 月，我们有 12 起与站点设置说明相关的报告事件，这些事件可能导致站点设置错误。根据这些数据，我们进行了五次与不正确站点设置说明相关的 BTA 分析。我们 QA 计划中旨在检查站点设置说明中潜在错误的个别控制措施都没有达到被归类为关键保护措施或障碍的稳健性水平。
导致患者伤害的事件相对较少，这导致我们通常假设我们已经有足够和有效的控制措施来防止严重的人为错误导致严重的患者后果。根据我们的 BTA，我们质疑我们对个别控制措施的细节了解程度。为了达到高可靠性组织（HRO）实现的安全水平，我们需要更好地确保我们的控制措施像我们假设的那样可靠和稳健。
