Abstract
The lessons learned from completing a risk assessment of a radiotherapy information system in a public hospital are presented. A systems engineering perspective with respect to the risk assessment was adopted. Standard engineering tools modified for application in healthcare environments were applied, e.g. HFMEATM. It was found that there was a complete absence of the application of systems engineering at the development stage of the radiotherapy system, however aspects of quality systems, i.e. process improvement, were present at the operating stage. Team work played a significant role in the successful operation of the system. However, in contrast to most engineering systems, team composition was highly heterogeneous as roles were clearly defined by professional qualification. There were strong boundaries between the radiotherapy team and other teams in the hospital. This was reflected by their lack of concern regarding the availability of patient information beyond their own department.
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Hollywood, D.P.: The Development of Radiation Oncology services in Ireland. Department of Health and Children, Dublin (2003)
WHO: Radiotherapy Risk Profile. World Health Organization, Geneva (2008)
Ihde, D.: The Structure of Technology Knowledge. International Journal of Technology and Design Education 7, 73–79 (1997)
Graber, M.: The Safety of Computer-Based Medication Systems. Arch. Intern. Med. 164, 339–340 (2004)
Patton, G.A., Gaffney, D.K., Moeller, J.H.: Facilitation of radiotherapeutic error by computerized record and verify systems. International Journal of Radiation Oncology*Biology*Physics 56, 50–57 (2003)
Barthelemy-Brichant, N., Sabatier, J., Dewé, W., Albert, A., Deneufbourg, J.-M.: Evaluation of frequency and type of errors detected by a computerized record and verify system during radiation treatment. Radiotherapy and Oncology 53, 149–154 (1999)
Spear, M.E.: Ergonomics and human factors in health care settings. Annals of Emergency Medicine 40, 213–216 (2002)
Wears, R.L., Cook, R.I., Perry, S.J.: Automation, interaction, complexity, and failure: A case study. Reliability Engineering & System Safety 91, 1494–1501 (2006)
Aspley, S.J.: Implementation of ISO 9002 in cancer care. International Journal of Health Care Quality Assurance 9, 28–30 (1996)
The Royal College of Radiologists, Society and College of Radiographers, Institute of Physics and Engineering in Medicine, National Patient Safety Agency, British Institute of Radiology: Towards Safer Radiotherapy The Royal College of Radiologists, London (2008)
Nenot, J.C.: Radiation accidents: lessons learnt for future radiological protection. International Journal of Radiation Biology 73, 435–442 (1998)
Ash, D.: Lessons from Epinal. Clinical Oncology 19, 614–615 (2007)
International Atomic Energy Agency: International action for the protection of radiological patients. IAEA, Vienna (2002)
Yeung, T.K., Bortolotto, K., Cosby, S., Hoar, M., Lederer, E.: Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period. Radiotherapy and Oncology 74, 283–291 (2005)
Goddard, P., Leslie, A., Jones, A., Wakeley, C., Kabala, J.: Error in radiology. Br. J. Radiol. 74, 949–951 (2001)
Kohn, K.T., Corrigan, J.M., Donaldson, M.S. (eds.): To Err is Human: Building a Safer Health System. Institute of Medicine. National Academy Press, Washington (1999)
Tang, B., Hanna, G.B., Cuschieri, A.: Analysis of errors enacted by surgical trainees during skills training courses. Surgery 138, 14–20 (2005)
Tissot, E., Cornette, C., Demoly, P., Jacquet, M., Barale, F., Capellier, G.: Medication errors at the administration stage in an intensive care unit. Intensive Care Medicine 25, 353–359 (1999)
Chadwick, L., Fallon, E.F.: Applying Human Error Identification in Dental Care. In: Pacholski, L.M., Trzcielinski, S. (eds.) Proceedings of the 11th Conference on Human Aspects of Advanced Manufacturing: Agility and Hybrid Automation. 4th International Conference ERGON_AXIA. IEA Press, Poznan University of Technology (2007)
Wetterneck, T.B., Skibinski, K.A., Roberts, T.L., Kleppin, S.M., Schroeder, M.E., Enloe, M., Rough, S.S., Hundt, A.S., Carayon, P.: Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. American Journal of Health-System Pharmacy 63, 1528–1538 (2006)
Latino, R.J.: Optimizing FMEA and RCA efforts in health care. ASHRM 24, 21–27 (2004)
Stockwell, D.C., Slonim, A.D.: Quality and Safety in the Intensive Care Unit. J. Intensive Care Med. 21, 199–210 (2006)
Senders, J.W.: FMEA and RCA: the mantras of modern risk management. Qual. Saf. Health Care 13, 249–250 (2004)
Derosier, J., Stalhandske, E., Bagian, J.P., Nudell, T.: Using Health Care Failure Mode and Effect AnalysisTM: The VA National Center for Patient Safety’s Prospective Risk Analysis System. Journal of Quality Improvement 28, 248–267 (2002)
Hughes, S.: Your Service, Your Say The Policy and Procedures for the Management of Consumer Feedback to include Comments, Compliments and Complaints in the Health Service Executive (HSE). Health Service Executive, Dublin (2008)
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Fallon, E.F., Chadwick, L., van der Putten, W. (2009). Learning from Risk Assessment in Radiotherapy. In: Duffy, V.G. (eds) Digital Human Modeling. ICDHM 2009. Lecture Notes in Computer Science, vol 5620. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-02809-0_53
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