Real-time management of incident learning reports in a radiation oncology department

Jean L Wright,Arti Parekh, Byung-Han Rhieu,Valentina Opris, Annette Souranis,Amanda Choflet, Akila N. Viswanathan,Theodore L. DeWeese, Todd McNutt,Stephanie A. Terezakis

Practical Radiation Oncology(2018)

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摘要
Our experience demonstrates that workflow event reports are far more common than near-misses and that near-miss events are more likely to both originate and be discovered in later treatment phases. The frequency of workflow reports highlights the imperative need for safety and operational teams to work collaboratively to maximize the benefit of ILS. We suggest a potential utility of the RPN system to guide mitigation strategies for future near-miss events.
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