Collection and Evaluation of Incidents in a Radiotherapy Department

Portaluri, Maurizio; Fucilli, Fulvio Italo Maria; Gianicolo, Emilio Antonio Luca; Tramacere, Francesco; Francavilla, Maria Carmen; Tommaso, Cristina De; Castagna, Roberta; Pili, Giorgio

doi:10.1007/s00066-010-2141-2

Cited by 21 publications

(14 citation statements)

References 25 publications

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“…The next two levels of HFACS are often infrequently investigated and, therefore, are underrepresented in most accident reports or narrative summary reports, meaning causal factors at the unsafe supervision and organizational tier are associated with fewer incident/accident cases than those at other tiers of HFACS (e.g., Wiegmann & Shappell, 2001a;Shappell et al, 2007). For the research available, the leading causal factors for each of these levels are inadequate supervision (e.g., Baysari, McIntosh, & Wilson, 2008;Gaur, 2005;Li, Harris, & Yu, 2008;Portaluri et al, 2010) and organizational processes (e.g., Baysari, McIntosh, & Wilson, 2008;Lenne, Salmon, Liu, & Trotter, 2012;Li, Harris, & Yu, 2008;Patterson & Shappell, 2010;Patterson, 2009;Portaluri et al, 2010).…”

Section: 521 Comprehensivenessmentioning

confidence: 99%

Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability

et al. 2016

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Human error has been identified as the primary contributing cause for up to 80% of the accidents in complex, high risk systems such as aviation, oil and gas, mining and healthcare. Many models have been proposed to analyze these incidents and identify their causes, focusing on the human factor. One such safety model is the Human Factors Analysis and Classification System (HFACS), a comprehensive accident investigation and analysis tool which focuses not only on the act of the individual preceding the accident but on other contributing factors in the system as well. Since its development, HFACS has received substantial research attention; however, the literature on its reliability is limited. This study adds to past research by investigating the overall intra-rater and inter-rater reliability of HFACS in addition to the intra-rater and inter-rater reliability for each tier and category. For this investigation, 125 coders with similar HFACS training coded 95 causal factors extracted from actual incident/accident reports from several sectors. The overall intra-rater reliability was evaluated using percent agreement, Krippendorff"s Alpha, and Cohen"s Kappa, while the inter-rater was analyzed using percent agreement, Krippendorff"s Alpha, and Fleiss" Kappa. Because of analytical limitations, only percent agreement and Krippendorff"s Alpha were used for the intra-rater evaluation at the individual tier and category level and Fleiss" Kappa and Krippendorff"s Alpha, for the corresponding inter-rater evaluation. The overall intra-rater and inter-rater results for the tier level and the individual HFACS tiers achieved acceptable reliability levels with respect to all agreement v ACKNOWLEDGMENTS First, I would like to express my sincerest thanks and gratitude to Allah, who is the source of my success for accomplishing this research. I acknowledge the insightful instruction and guidance of my advisors, Dr. Anand Gramopadhye and Dr. Scott Shappell, who have given me continuous support throughout this research. I also thank my committee members Dr. Kurz and Dr. Sharp, for their valuable suggestions for improving the quality of this work. I am especially grateful to Dr. Julia Sharp; her guidance, constructive feedback, and support significantly contributed to the accomplishment of this research. Special thanks also go to Barbara Ramirez, Director of the Class of 1941 Studio for Student Communication, for her technical help and support in editing this research. Much appreciation goes to my family: my parents, Omar and Mohra; my siblings, Sassia, Abdel-Hakim, Eman, Najmeddien, Wafa, and Housameddien; and my mother in law, Aisha. I am blessed that you are my family and am especially grateful for your prayers, thoughtfulness and emotional support. Special gratitude is also extended to my other family members, aunts, uncles, nieces, nephews, and cousins. Finally, I am very grateful to my husband, Ahmed; I could not have done any of this without you.

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Section: 521 Comprehensivenessmentioning

confidence: 99%

Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability

et al. 2016

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“…The primary radiotherapy-specific method for reactive analysis of events is the Human Factor Analysis and Classification System (HFACS) [22], a detailed event analysis method for identifying both latent and active failures. HFACS provides a highly practical framework to identify failures.…”

Section: Radiotherapy-specific Methodsmentioning

confidence: 99%

“…HFACS describes failure levels and identification of root causes. In Italy, a detailed version of HFACS has been developed specifically for radiotherapy [22]. The use of a causal tree (included in both CTA and ORION methods) is particularly valuable because it enables identification of causal relationships among events.…”

Section: Comparison Of Different Methods For Reactive Analysis Of Eventsmentioning

confidence: 99%

Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe

Malicki

Bly

Bulot³

et al. 2017

Radiotherapy and Oncology

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Most European countries have taken steps to implement European directives designed to reduce the probability and magnitude of accidents in radiotherapy. Variability between countries is substantial in terms of legal frameworks, tools used to conduct proactive risk assessment and reactive analysis of events, and in the reporting and learning systems utilized. These findings underscore the need for greater harmonisation in common terminology, classification and reporting practices across Europe to improve patient safety and to enable more reliable inter-country comparisons.

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“…Central task of quality management in modern radiotherapy is the avoidance of mistakes. One of the most dangerous and relatively common mistakes is the mix-up of patients (due to the same surname, or by missing concentration of the staff) [5]. This would mean, that the patient who is actually in the treatment room, receives the planned irradiation of another patient, resulting in completely different treatment volume definition and even dose fractionation.…”

Section: Patient Recognition: Higher Safety In Daily Clinical Practicmentioning

confidence: 99%

Three Simple Software Extensions for Automatic Presentation of Radiation Induced Toxicity, Sequelae and Treatment Outcomes, for Increasing Safety in Daily Therapeutic Routine, and for Enhancing Patient Comfort

Hermann¹,

Schober²,

Carl³

et al. 2016

Int J Radiol Radiat Oncol

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ToxReview: automatic correlation with toxicity and treatment concepts (target volume, radiation dose) to enable centre-referential description and surveillance of radiotherapeutic toxicity and treatment outcome In radiotherapy the oncology information system (OIS) "MOSAIQ" is widely used. As a supplementary module it allows the documentation of so called clinical assessments. In these electronic data sheets organ specific treatment related toxicity [according to Common Terminology Criteria for Adverse Events scales (CTC) and LENT-SOMA [4], can be coded, as well as tumor recurrences, metastases or death. For daily clinical practice the data entry form can be categorized according to the actual irradiated region (e.g. breast, pelvis, head and neck). For instance, in breast cancer patients only relevant organs are shown, but not bladder or rectum. Such an

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Collection and Evaluation of Incidents in a Radiotherapy Department

Abstract: collecting and analyzing internal incidents improves the operative procedures used in the department.

Cited by 21 publications

References 25 publications

Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability

Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability

Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe

Three Simple Software Extensions for Automatic Presentation of Radiation Induced Toxicity, Sequelae and Treatment Outcomes, for Increasing Safety in Daily Therapeutic Routine, and for Enhancing Patient Comfort

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