藉由跡近錯失與不良事件分析提升放射治療段病患的安全

Analysis of the Near Miss and Adverse Events to Improve Patient Safety in Radiotherapy

蔡芳惠(Fang-Hui Tsai) ； 陳馨順(Shin-Shun Chen) ； 鄧碧芬(Pi-Fen Teng) ； 吳銘哲(Ming-Che Wu) ； 謝忱希(Chen-His) ； 吳樂榮(Le-Jung Wu) ； 熊佩韋(Pei-Wei Shueng)

《中華放射線技術學雜誌》 39卷4期 (2015/12) Pp. 227-232

摘要

本研究目的是想改善在放射治療段的錯誤率進而提升病患於放射治療的安全性。經過團隊討論我們將放射治療段的錯誤率依跡近錯失（near miss）與不良事件（adverse events）兩大類分別建立分析項目及表格，共統計一台直線加速器及兩台導航螺旋刀操作三年的數據，先檢討第一年的統計結果並提出改善方法，之後應用於第二年及第三年。結果顯示第一年統計期間內跡近錯失的發生率為0.43%、第二年為0.34%、第三年則更減少到0.23%。不良事件第一年的發生率為0.01%，經過改善方法的實施，第二年及第三年的發生率則皆為零。本研究是台灣首次針對放射治療段，醫事放射師覆誦當位病患資訊管理系統的治療資料後再執行治療，並經過兩年實施的經驗與分析後，我們發現此改善方法確實可以大幅降低醫事放射師執行治療過程中的失誤，進而確保病人放射治療段的安全。

關鍵字

放射線治療 ； 跡近錯失 ； 不良事件 ； 病患安全

並列摘要

The purpose of this study is to collect and analyze the data of the error rate during the radiation therapy process and to improve the patients’ safety.We defined the near miss and adverse event happened at control room or radiotherapy room and formed their related tables which would be recordedbyradiologistseveryday.The error data of one Linac and two tomotherapy machines were collected for about years.We discussed and proposed the improvement planfor the second year based on the data of the first year. Similarly, we discussed and proposed the improvement plan for the third year according to data of the second year.The near-miss rateswere 0.43%, 0.34%,and 0.23% in the first, second, and third year, respectively.The adverse event ratein the first yearwas 0.01%and the adverse eventsdidnot happen in the following two years.The research is the first study to analyze the errors of treatment process in Taiwan.The main improvement plan is that the radiation therapists should check patient information by repeating patient name,patient number,plan name,plan label,treatment site and treatment times. We did find the improvement plan could prevent certain clinical misses and therefore ensure the patient’s safety.

並列關鍵字

radiotherapy ； near miss ； adverse event ； patient safety