| He Haiping,Peng Xudong,Luo Dashuang,et al.HFACS-based human factors analysis of radiotherapy safety incidents and exploration of incident chains[J].Chinese Journal of Radiological Medicine and Protection,2024,44(5):386-392 |
| HFACS-based human factors analysis of radiotherapy safety incidents and exploration of incident chains |
| Received:August 12, 2023 |
| DOI：10.3760/cma.j.cn112271-20230812-00043 |
| KeyWords:Human factors analysis and classification system Latent class analysis Human factor Radiotherapy incident |
| FundProject:国家自然科学基金(81972848,12205209) |
| Author Name | Affiliation | E-mail | | He Haiping | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | | | Peng Xudong | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | | | Luo Dashuang | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | | | Xiao Qing | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | | | Li Guangjun | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | | | Bai Sen | Radiotherapy Physics and Technology Center, Cancer Center, West China Hospital of Sichuan University, Chengdu 610041, China | baisen@scu.edu.cn |
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| Abstract:: |
| Objective To analyze human factors in radiotherapy safety incidents and identify their correction for the purpose of mining the latent incident chains. Methods A total of 60 radiotherapy safety incidents were included in the Radiation Oncology Incident Learning System (ROILS) for cause identification and frequency statistics using the Human Factors Analysis and Classification System (HFACS). Latent class analysis (LCA) was performed for the result to correlate the incident causes. Results Incidents in the protocol design stage were the most common, accounting for 35%. Adverse organizational climate, inadequate supervision, and personnel factors were the primary causes of incidents at each level of the HFACS, accounting for 4.66%, 15.68%, and 16.20%, respectively. Three latent incident chains were identified through LCA, comprising two originating from organizational climate issues and one from organizational process issues, which were passed down via various human factors or "loopholes" Conclusions HFACS assists in tracing the human factors at all levels that lead to radiotherapy safety incidents. The high-frequency causes and three latent chains of radiotherapy incidents found in this study can provide a guide for the development of targeted safety and defense measures. |
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