Risk Assessment in Radiotherapy - Lessons from Systems Engineering

摘要

Radiotherapy is a highly structured discipline in health care with well defined processes and patient flows. Errors in radiotherapy have been well documented and are Widely publicised. In this paper a systems engineering perspec-tive with respect to the risk assessment of a radiation oncology management system is reported with the aim to study any lessons which could be learned from this approach. The system is the Siemens/IMPAC LA NT IS™ system which was intro-duced in Galway University Hospitals in 2005. This system was the first fully electronic radiotherapy management system in Ireland, which allowed the introduction of paper- and film-less radiotherapy. A full risk assessment of the system was con-ducted using standard engineering tools modified for applica-tion in healthcare environments, e.g. HFMEA™. It was found that there was a complete absence of the application of systems engineering at the specification and implementation 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 sys-tems, team composition was highly heterogeneous as roles were clearly defined by professional qualification. There were itrong boundaries between the radiotherapy team and other teams in the hospital. This was reflected by their lack of con-cern regarding the availability of patient information beyond their own department.