对事故模型和事件分析技术的审查
Lawrence M Wong1, Todd Pawlicki1
1Department of Radiation Medicine & Applied Sciences, University of California San Diego, La Jolla, California, USA.
Journal of applied clinical medical physics
|February 2, 2025
概括
本综述探讨了辐射瘤学安全事故模型和事故分析技术. 考虑复杂相互作用的系统方法对于提高超越线性事件链的安全性至关重要.
科学领域:
- 医学物理 医学物理
- 辐射瘤学安全 辐射瘤学安全
- 系统工程 系统工程
背景情况:
- 放射性瘤学涉及具有固有的风险的复杂系统.
- 了解事故原因对于提高患者安全至关重要.
- 现有的事件分析方法在它们对复杂性的方法上有所不同.
研究的目的:
- 审查适用于放射瘤学的事故模型和事故分析技术.
- 为了比较事件链和系统模型的事故因果关系.
- 讨论各种分析技术的优缺点.
主要方法:
- 对事故模型的审查 (事件链,系统).
- 介绍事件分析技术 (RCA,伦敦协议,AcciMap,CAST).
- 讨论相关的安全概念 (NAT,FRAM,Bowtie分析).
主要成果:
- 事件链模型可以识别因果因素和干预措施.
- 系统模型揭示了影响事故的相互作用.
- 将人类行为转化为决策缺陷和情境因素是改进的关键.
结论:
- 对事件分析的系统方法为复杂的辐射瘤系统提供了细微的理解.
- 整合安全科学和人类因素专业知识可以增强分析.
- 采用系统视角对于在复杂的医疗环境中推进安全至关重要.
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