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  1. Lessons learned from investigations of therapy misadministration events.

    Article - En anglais

    Purpose 

    Investigation teams composed of Idaho National Engineering Laboratory (INEL), United States Nuclear Regulatory Commission (NRC), and subcontractor personnel performed detailed investigations and analyses of seven misadministration events that were specifically selected on the basis of particular characteristics.

    These events were analyzed to identify the direct causes, contributing factors, actions to mitigate the event, and the consequences of these events.

    The INEL also sought to determine the role played by the recent Quality Management Rule.

    Methods and Materials 

    The investigation teams were multidisciplinary and, depending on the nature of the event, included three or more team members with appropriate expertise in the areas of radiation oncology, medical physics, nuclear medicine technology, risk analysis, and human factors.

    The investigations focused on the general areas of causes of the event, mitigating actions, and corrective actions.

    Seven misadministration events were investigated by the teams during 1991 and 1992.

    Results 

    Results from the events investigated indicated that (a) the institutional traditions of some licensees contributed to the potential for misadministrations, (b) many misadministrations occurred primarily due to lack of procedures or procedures that were not clearly written, (c) some licensees in this study had not effectively implemented their Quality Management programs, and (d) limited involvement on the part o...

    Mots-clés Pascal : Médecine nucléaire, Gestion, Gestion qualité, Réglementation, Facteur humain, Accident, Traitement

    Mots-clés Pascal anglais : Nuclear medicine, Management, Quality management, Regulation, Human factor, Accident, Treatment

    Logo du centre Notice produite par :
    Inist-CNRS - Institut de l'Information Scientifique et Technique

    Cote : 96-0104683

    Code Inist : 002B30A04C. Création : 199608.