Joint Commission journal on quality and safety最新文献

An Interview with Peter Pronovost Peter Pronovost访谈

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30077-8

Steven Berman

引用次数: 2

Joint Commission International (JCI): A Partner in Quality and Safety 国际联合委员会(JCI):质量和安全合作伙伴

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30103-6

Paul vanOstenberg D.D.S, M.S. (Managing Director)

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引用次数: 4

Editorial Advisory Board 编辑顾问委员会

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30101-2

引用次数: 0

Improving the Quality of Data in Your Database: Lessons from a Cardiovascular Center 提高数据库中的数据质量:来自心血管中心的经验教训

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30081-X

Constance K. Haan M.D. (Senior Medical Director of System Outcomes and Effectiveness), Mark Adams B.S.H. (Cardiology Data Manager), Ray Cook R.N. (Cardiac Surgery Data Manager)

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引用次数: 8

Human Factors Risk Management as a Way to Improve Medical Device Safety: A Case Study of the Therac 25 Radiation Therapy System 人为因素风险管理作为提高医疗器械安全性的途径:以therac25放射治疗系统为例

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30082-1

Edmond W. Israelski Ph.D., C.H.F.P. (Program Manager), William H. Muto Ph.D., C.P.E. (Principal Human Factors Engineer)

{"title":"Human Factors Risk Management as a Way to Improve Medical Device Safety: A Case Study of the Therac 25 Radiation Therapy System","authors":"Edmond W. Israelski Ph.D., C.H.F.P. (Program Manager), William H. Muto Ph.D., C.P.E. (Principal Human Factors Engineer)","doi":"10.1016/S1549-3741(04)30082-1","DOIUrl":"10.1016/S1549-3741(04)30082-1","url":null,"abstract":"<div><h3>Background</h3><p>In a fatal incident in 1984 much discussed in the literature, a patient received 16,000 rads instead of the intended 180 rads when undergoing radiation treatment. This incident likely could have been prevented by the use of risk analysis.</p></div><div><h3>Risk Analysis</h3><p>Risk analysis techniques to identify use errors have received increasing attention in health care. Use errors are defined as a pattern of predictable human errors that can be attributable to inadequate or improper design. Among the most widely used of the risk analysis tools are Failure Modes and Effects Analysis (FMEA) and fault tree analysis (FTA). The Therac 25 Radiation Therapy System incidents involved a combination of technical failures (software and possibly hardware) combined with human behavior resulting in catastrophic radiation overdoses.</p></div><div><h3>Summary and Conclusions</h3><p>From a manufacturer’s perspective, FMEAs and FTAs are valuable methods to systematically evaluate a medical device design’s potential for inducing use errors. When these risk analyses are done early in the development cycle, potential faults and their resulting hazards are identifiable and much easier to mitigate with error-reducing designs. These risk management methods are excellent complements to other important user-centered design best practices.</p></div>","PeriodicalId":84970,"journal":{"name":"Joint Commission journal on quality and safety","volume":"30 12","pages":"Pages 689-695"},"PeriodicalIF":0.0,"publicationDate":"2004-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1549-3741(04)30082-1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25070393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 49

Acknowledgments 致谢

Joint Commission journal on quality and safety Pub Date : 2004-12-01 DOI: 10.1016/S1549-3741(04)30098-5

引用次数: 0

An interview with Lucian Leape. 卢西安·利普的采访。

Joint Commission journal on quality and safety Pub Date : 2004-12-01

Lucian L Leape