[A Human Factors Study Using VTA for Incident Cases in Radiotherapy]

Area of Science:

• Medical Physics
• Radiation Oncology
• Human Factors Engineering

Background:

• Increasing precision in radiotherapy has led to higher workloads.
• Balancing treatment efficiency and thoroughness is challenging, increasing the risk of human error.
• Human error in healthcare settings is a significant concern impacting patient safety.

Purpose of the Study:

• To analyze incident cases in radiotherapy from a human factors perspective.
• To investigate the role of resilience in the occurrence of human errors.
• To identify factors contributing to human errors in high-precision radiotherapy.

Main Methods:

• Case study analysis of five incident cases across four facilities.
• Application of variation tree analysis to identify contributing factors.
• Examination of resilience actions and their impact on error occurrence.

Main Results:

• Patient factors were present in all analyzed incident cases.
• Incidents often stemmed from deviations due to unfamiliar situations and operations.
• In four out of five cases, resilience actions or judgments contributed to the incident.
• Human errors resulted from the simultaneous occurrence of patient and human factors like high workload and interruptions.

Conclusions:

• Reducing human error requires addressing time pressure, multitasking, and improving work environments.
• Enhancing the effectiveness of resilience through better working conditions is crucial.
• Clarifying ambiguous rules, standardizing procedures, and promoting standardized working methods can mitigate errors.