[Analysis of Preventive Cases Using Resilience Engineering in Radiotherapy Department].

Abstract

Resilience engineering is the ability of a system to adjust its own functions and maintain the required behavior in the face of changes and disturbances, and resilience potential is a necessary requirement. We aimed to clarify the relationship between resilience potential and error prevention cases. Based on the error cases reported in our department, we aggregated the relationship with resilience potential for each radiation treatment process. As a result of tabulating the relationship, we were able to recognize and prevent errors by taking preventive measures from past cases. On the other hand, in cases that slipped through the check mechanism, errors were discovered because of a sense of discomfort in unusual situations, and some error cases could be prevented by increasing the resilience potential. This study found that preparation, observation, coping, and utilization of past experiences are related to resilience potential in preventive cases.