重新评估肺部SBRT故障模式的临床影响以及放射治疗部门的效应分析
Sergi Benavente1, Alexandra Giraldo2, Alejandro Seoane3
1Department of Radiation Oncology, Vall d'Hebron University Hospital Campus, Barcelona, Spain. sergi.benavente@vallhebron.cat.
概括
肺部立体体辐射疗法 (SBRT) 的故障模式和影响分析 (FMEA) 确定了高风险区域. 重新分析显示,复杂性增加将风险转移到人为因素和通信错误,需要数字解决方案.
科学领域:
- 辐射瘤学 辐射瘤学
- 医学物理 医学物理
- 提高质量 提高质量
背景情况:
- 像肺SBRT这样的辐射治疗的复杂性增加可能会影响临床结果.
- 故障模式和影响分析 (FMEA) 是识别和减轻复杂医疗程序中的风险的关键工具.
研究的目的:
- 用FMEA重新评估肺部SBRT中的风险.
- 了解治疗复杂性和患者体积如何影响失效模式及其原因随时间推移.
主要方法:
- 一个经验丰富的多学科团队进行了初步的FMEA和3年后的重新评估.
- 开发了一个过程地图,以识别潜在的故障模式 (FMs) 和其原因.
- 将FMEA的初始和修订分析进行比较,以评估风险和纠正行动的变化.
主要成果:
- 确定了232个FM,其中计划批准,目标轮和患者评估是高风险的过程.
- 实施了标准化计划批准和预处理检查清单等纠正措施,大大降低了风险.
- 重新评估显示,人为因素增加和沟通错误是原因,由于复杂性和患者数量,错误剂量输送的可能性更高.
结论:
- 肺部SBRT FMEA有效识别和减轻高风险疾病.
- 计划批准仍然是SBRT过程中的一个关键弱点.
- 随着治疗复杂性和患者数量的增加,需要先进的解决方案,如数字工具和人工智能,以解决人类和通信错误,并预防不良事件.
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