帳  號 
密  碼 
加入會員忘記密碼  
 
學會簡介
學會章程
大事紀要
學會組織
會務活動
歷屆年會
加入會員
最新訊息
人因會訊專區
人因工程相關研討會
人因諮詢
關鍵議題
線上會議
國內外人因案例
出版品
學術著作
學生專題
相關網站
投稿說明
評審程序
我要投稿
 
行動版 | English
 
 
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