10 年间各种治疗计划系统操作中的人为错误分析

IF 1.9 4区 医学 Q2 BIOLOGY Journal of Radiation Research Pub Date : 2024-09-09 DOI:10.1093/jrr/rrae053
Kotaro Iijima, Hiroki Nakayama, Satoshi Nakamura, Takahito Chiba, Yasunori Shuto, Yuka Urago, Shuka Nishina, Hironori Kishida, Yuta Kobayashi, Jun Takatsu, Junichi Kuwahara, Ako Aikawa, Tomonori Goka, Tomoya Kaneda, Naoya Murakami, Hiroshi Igaki, Hiroyuki Okamoto
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引用次数: 0

摘要

本研究旨在总结和报告由医学物理学家收集的与治疗计划相关的错误数据。根据 10 年的错误报告数据进行了以下分析:(1) 列出发生的高风险错误;(2) 治疗次数与错误率之间的关系;(3) 使用 Eclipse 脚本应用编程接口的自动计划检查系统 (APCS) 的实用性;(4) 人为因素与错误率之间的关系。在使用自动计划检查系统前后,错误率出现了差异。APCS 将高风险错误的错误率降低了约 1%,将低风险错误的错误率降低了 3%。治疗次数与错误率呈负相关。因此,我们研究了医学物理学家的工作量与错误发生率之间的关系,结果发现,巨大的工作量可能会导致忽略错误。同时,医学物理学家人数的增加可能会导致发现更多的错误。错误数量与临床经验较少的医生数量相关;临床经验较少的医生数量越多,错误率越高。这可能是由于临床经验不足的医生缺乏培训。提供充分培训的环境非常重要,因为临床实践经验不足很容易直接导致错误的发生。在任何环境下,都需要增加计划检查人员,这是消除错误的一个重要因素。
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Analysis of human errors in the operation of various treatment planning systems over a 10-year period
The present study aimed to summarize and report data on errors related to treatment planning, which were collected by medical physicists. The following analyses were performed based on the 10-year error report data: (1) listing of high-risk errors that occurred and (2) the relationship between the number of treatments and error rates, (3) usefulness of the Automated Plan Checking System (APCS) with the Eclipse Scripting Application Programming Interface and (4) the relationship between human factors and error rates. Differences in error rates were observed before and after the use of APCS. APCS reduced the error rate by ~1% for high-risk errors and 3% for low-risk errors. The number of treatments was negatively correlated with error rates. Therefore, we examined the relationship between the workload of medical physicists and error occurrence and revealed that a very large workload may contribute to overlooking errors. Meanwhile, an increase in the number of medical physicists may lead to the detection of more errors. The number of errors was correlated with the number of physicians with less clinical experience; the error rates were higher when there were more physicians with less experience. This is likely due to the lack of training among clinically inexperienced physicians. An environment to provide adequate training is important, as inexperience in clinical practice can easily and directly lead to the occurrence of errors. In any environment, the need for additional plan checkers is an essential factor for eliminating errors.
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来源期刊
CiteScore
3.60
自引率
5.00%
发文量
86
审稿时长
4-8 weeks
期刊介绍: The Journal of Radiation Research (JRR) is an official journal of The Japanese Radiation Research Society (JRRS), and the Japanese Society for Radiation Oncology (JASTRO). Since its launch in 1960 as the official journal of the JRRS, the journal has published scientific articles in radiation science in biology, chemistry, physics, epidemiology, and environmental sciences. JRR broadened its scope to include oncology in 2009, when JASTRO partnered with the JRRS to publish the journal. Articles considered fall into two broad categories: Oncology & Medicine - including all aspects of research with patients that impacts on the treatment of cancer using radiation. Papers which cover related radiation therapies, radiation dosimetry, and those describing the basis for treatment methods including techniques, are also welcomed. Clinical case reports are not acceptable. Radiation Research - basic science studies of radiation effects on livings in the area of physics, chemistry, biology, epidemiology and environmental sciences. Please be advised that JRR does not accept any papers of pure physics or chemistry. The journal is bimonthly, and is edited and published by the JRR Editorial Committee.
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