Smith Sandie, Wallis Andrew, King Odette, Moretti Daniel, Vial Philip, Shafiq Jesmin, Barton Michael B, Xing Aitang, Delaney Geoff P
Liverpool Cancer Therapy Centres, Liverpool, NSW, Australia.
Macarthur Cancer Therapy Centre, Campbelltown, NSW, Australia.
Tech Innov Patient Support Radiat Oncol. 2020 Mar 9;14:15-20. doi: 10.1016/j.tipsro.2020.02.001. eCollection 2020 Jun.
Fifteen years of reported incidents were reviewed to provide insight into the effectiveness of an Incident Learning System (ISL). The actual error rate over the 15 years was 1.3 reported errors per 1000 treatment attendances. Incidents were reviewed using a regression model. The average number of incidents per year and the number of incidents per thousand attendances declined over time. Two seven-year periods were considered for analysis and the average for the first period (2005-2011) was 6 reported incidents per 1000 attendances compared to 2 incidents for the later period (2012-2018), p < 0.05. SAC 1 and SAC 2 errors have reduced over time and the reduction could be attributed to the quality assurance aspect of IGRT where the incident is identified prior to treatment delivery rather than after, reducing the severity of any potential incidents. The reasoning behind overall reduction in incident reporting over time is unclear but may be associated to quality and technology initiatives, issues with the ISL itself or a change in the staff reporting culture.
回顾了15年的报告事件，以深入了解事件学习系统（ISL）的有效性。15年间的实际错误率为每1000次治疗就诊有1.3起报告错误。使用回归模型对事件进行了审查。每年的事件平均数量和每千次就诊的事件数量随时间下降。分析考虑了两个七年期，第一个时期（2005 - 2011年）每1000次就诊的报告事件平均为6起，而后期（2012 - 2018年）为2起，p < 0.05。SAC 1和SAC 2错误随时间减少，这种减少可归因于图像引导放射治疗（IGRT）的质量保证方面，即事件在治疗交付前而非之后被识别，从而降低了任何潜在事件的严重程度。随着时间推移事件报告总体减少背后的原因尚不清楚，但可能与质量和技术举措、ISL本身的问题或员工报告文化的变化有关。
