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- W2128831871 abstract "Aim of this study is to reduce human errors in external beam radiation therapy by accumulated experiences. We collected incidents (including near misses) from May 2009 to April 2013 with internal voluntary reporting system. Pre-treatment primary and additional independent checks were performed in our procedures of radiation therapy (RT). After starting treatment, interdisciplinary reviews were performed every week by radiation oncology team. The report worksheet was comprised of following contents: phase of RT procedure causing incident, phase of discovery, how discovered, date of incident, date of discovery, staff involved in incident and member who detected it. Discovered errors were classified according to classification of Toward safer radiation therapy published by The Royal college of radiologists. All staff were allowed to discuss incidents and determine corrective action in the annual team meeting and when required. New (modified) procedures were known to all staffs in morning meeting and emails. Over the study interval, 49 incidents among 2350 courses were captured. Incidents occurred most frequently during treatment planning (74%) and when treatment delivery (20%). The proportion of actual incidents were 3.9%, 2.2%, 1.1% and 1.1% in the first, second, third and fourth year. We found significant reduction proportion of actual incidents in the third and fourth year compared to the first year (p < 0.01). Incidents and near misses can be reduced to minimum possible consistence with the voluntary reporting systems." @default.
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- W2128831871 date "2014-09-01" @default.
- W2128831871 modified "2023-09-27" @default.
- W2128831871 title "Feasible Strategy for Reduction of Individual Human Failures in External Radiation Therapy Workflow" @default.
- W2128831871 doi "https://doi.org/10.1016/j.ijrobp.2014.05.2165" @default.
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