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首页> 美国卫生研究院文献>Frontiers in Oncology >Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine
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Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

机译：放射医学中的事件学习和故障模式与效果分析指导安全措施

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By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.
机译：通过在结构-过程-结果框架中结合事件学习和过程故障模式与效果分析（FMEA），我们为放射医学实践创建了风险概况，并实施了以证据为基础的针对患者安全的风险缓解计划。基于对我们部门事故报告系统中报告的事件的反应性审查以及积极的FMEA，我们确定了无纸化放射医学过程中的高安全风险程序和潜在风险因素。实施了旨在减轻相关严重性，发生可能性和可检测性风险的六项举措。这些措施包括护理途径和毒性分级的标准化，治疗前规划的同行评审，阻止延误的流程的政策，电子白板以增强协调性，以及使用六个西格玛指标来监控运营效率。在部门结构的框架内，使用特定于过程和结果的指标来评估这些计划在三年期间的有效性。事故报告增加了47％，不良事件没有增加。已经使用了超过97％的临床依从率的护理途径。在进行治疗计划和使用白板之前实施同行评审为主动检测和纠正错误提供了机会。高风险程序延迟的发生率下降了两倍。通常会在历史上已被紧急送达的案件中强制执行患者治疗开始延迟。高风险程序的Z分数已从1.78稳步提高到2.35。这些举措导致在三年期间通过一系列基于证据的指标来持续降低故障模式风险。这些通过将其转化为临床实践来增强或结合许多已发布的放射医学患者安全建议。

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