BN‐HFACS based human factors analysis of radiotherapy planning safety incidents
10.3760/cma.j.cn113030-20241218-00481
- VernacularTitle:基于BN‐HFACS的放疗计划不良事件人为因素分析
- Author:
Ran LUO
1
;
Xudong PENG
;
Chen LI
;
Haiping HE
;
Qiang WANG
;
Xuetao WANG
;
Hong QUAN
;
Guangjun LI
Author Information
1. 武汉大学物理科学与技术学院，武汉 430072
- Publication Type:Journal Article
- Keywords:
Radiotherapy;
Human factors analysis and classification system;
Human factors;
Radiotherapy planning;
Bayesian network;
Sensitivity analysis
- From:
Chinese Journal of Radiation Oncology
2025;34(8):804-810
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To investigate human factors underlying radiotherapy planning safety incidents and quantitatively explore their interrelationships.Methods:A total of 1 619 safety incidents recorded in the automated plan checking system developed by West China Hospital of Sichuan University were utilized. Human factors were identified and statistically analyzed using the Human Factors Analysis and Classification System (HFACS). A Bayesian network model was developed and combined with sensitivity analysis for quantitative assessment.Results:Key contributing factors included organizational processes (12.89%), inadequate supervision (11.85%), and personnel factors (13.50%). Utilizing the established HFACS Bayesian network hybrid model in conjunction with sensitivity analysis, it has been found that the most significant influences on skill‐based errors and decision errors were condition of operators and environmental factors, with corresponding indices of 0.96 and 0.76. Additionally, personnel factors had the greatest impact on routine, with an index of 3.51.Conclusions:Key contributing factors span all HFACS levels, with organizational processes, supervision, personnel, and condition of operators each playing a significant role. Upstream factors — such as organizational climate, environment factors, and personnel factors — strongly influence downstream risks. These offer actionable insights for developing targeted safety protocols.
