评估两个放射肿瘤学部门的事故学习系统和安全文化。

Evaluating incident learning systems and safety culture in two radiation oncology departments.

机构信息

Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia.

Department of Radiation Oncology, Blacktown Cancer & Haematology Centre, Sydney, New South Wales, Australia.

出版信息

J Med Radiat Sci. 2022 Jun;69(2):208-217. doi: 10.1002/jmrs.563. Epub 2021 Dec 9.

Abstract

INTRODUCTION

Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC.

METHODS

A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs.

RESULTS

Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS.

CONCLUSION

An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.

摘要

简介

放射肿瘤学患者的治疗路径较为复杂。这种复杂性增加了出现风险和潜在错误的可能性。为了降低风险和避免错误发生,除了使用事件学习系统(ILS)外,还制定了全面的安全和质量管理计划。健全的 ILS 依赖于部门内的安全文化(SC)。本研究的目的是评估两个紧密相连的放射肿瘤学部门对 SC 和 ILS 的认知和理解,并利用评估结果考虑对部门 ILS 和 SC 进行可能的质量改进(QI)。

方法

在两个部门中,向放射肿瘤学家、放射治疗师和放射肿瘤医学物理学家分发了一份评估 SC 和当前使用的 ILS 认知的调查问卷。对 95 名员工的回答进行了评估(占员工总数的 63%)。调查结果用于确定 SC 和当地 ILS 在哪些方面需要改进。

结果

不同专业群体之间存在差异。67%的受访者表示当前 ILS 使用存在障碍。在评估的每个领域都显示出积极的 SC:69%的人表示部门实行无责文化。一个部门发现的障碍促使一个 QI 项目制定了一个新的报告系统和流程,以改善部门学习并修改整体 ILS。

结论

已经建立了对 SC 的理解和对 ILS 的态度,并利用这些知识来改进 ILS 报告、事件反馈、部门学习和 QA 计划。随着系统的发展,这可以用于未来的比较。

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