title: Incidents analysis in radiation therapy: application of the human factors analysis and classification system.
abstract: The purpose of this investigation was to analyse incidents discovered in our radiation therapy department by means of human factor analysis and classification system (HFAC S). We adapted the original framework of the HFAC S and apply it to the analysis of incidents discovered in our radiotherapy department during a five-year period. Results showed that recurrent causal factors of incidents were attention failures and distracted/overconfidence behaviour as well as loss of situational awareness and mental fatigue. In our radiation therapy department the HFAC S allowed to highlight recurrent errors causal factors. Consequently we defined corrections factors for operators behaviour and implemented an operational protocol which improve operators attitude.
authors.affiliation: UOC di Radioterapia, ASL BR Di Summa, Ospedale Perrino, Brindisi, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Portaluri
authors.forename: Fulvio I M
authors.initials: FI
authors.lastname: Fucilli
authors.forename: Santa
authors.initials: S
authors.lastname: Bambace
authors.forename: Roberta
authors.initials: R
authors.lastname: Castagna
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: De Luca
authors.forename: Giorgio
authors.initials: G
authors.lastname: Pili
authors.forename: Vittorio
authors.initials: V
authors.lastname: Didonna
authors.forename: Francesco
authors.initials: F
authors.lastname: Tramacere
authors.forename: Maria Carmen
authors.initials: MC
authors.lastname: Francavilla
authors.forename: Angela
authors.initials: A
authors.lastname: Leone
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Leo
mesh_terms: D003627:Data Interpretation, Statistical; D005163:Factor Analysis, Statistical; D006801:Humans; D016273:Occupational Exposure / Q000009:adverse effects* / Q000145:classification*; D011878:Radiotherapy / Q000009:adverse effects*; D013647:Task Performance and Analysis