| |
|
|
|
|
|
 |
| |
 名稱 |
Preventing human errors: case study of brachytherapy misadministration |
| 類型 |
會議論文 |
| 年份 |
2003 |
| 著作人 |
Shi-Woei Lin;Bruce Thomadsen |
| 摘要 |
Errors during radiotherapy， as with many forms of medical treatment， carry the possibility of severe injury or death. When establishing methods for preventing errors， information on what errors have occurred in the past proves valuable in directing attention to aspects of a procedure posing the greatest risk. In this article， we use the root cause analysis tree， a risk analysis technique common in other industries， to investigate two brachytherapy adverse events. Instead of blaming individuals and using human errors as an explanation of the failure， we explore the latent conditions， system errors， and design issues associated with the whole system. The results indicate that the system failures such as rushed environment from lack of staffing or the software designs involve default setting and culture mismatch usually set the stage for the human errors. The verification procedures and protocols for intercepting these active human errors are also not effective. The methodology of re-engineering the system and the quality management tools and safeguards for preventing future errors are also discussed. |
| 關鍵字 |
medical errors;patient safety;brachytherapy;misadministrations;root cause analysis |
| 全文下載 |
 您無權限下載
|
|
| |
|
|
