HFACS-based human factors analysis of radiotherapy safety incidents and exploration of incident chains
10.3760/cma.j.cn112271-20230812-00043
- VernacularTitle:基于人为因素分析及分类系统的放射治疗安全事件人为因素分析及事故链探究
- Author:
Haiping HE
1
;
Xudong PENG
;
Dashuang LUO
;
Qing XIAO
;
Guangjun LI
;
Sen BAI
Author Information
1. 四川大学华西医院肿瘤中心放射物理技术中心，成都 610041
- Keywords:
Human factors analysis and classification system;
Latent class analysis;
Human factor;
Radiotherapy incident
- From:
Chinese Journal of Radiological Medicine and Protection
2024;44(5):386-392
- CountryChina
- Language:Chinese
-
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.
