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Cancer Prevention & Current Research

Research Article Volume 13 Issue 4

Radiation safety culture quantification in radiation medicine practice with time-spatial decomposition binary equal weight stakeholder model

Kaile Li

GenesisCare/Varian Medical System, USA

Correspondence: Kaile Li, GenesisCare/Varian Medical System, 2000 Foundation Way, Suite 1100 Martinsburg, WV, 21742, USA , Tel 3042628202

Received: July 14, 2022 | Published: July 25, 2022

Citation: Kaile L. Radiation safety culture quantification in radiation medicine practice with time-spatial decomposition binary equal weight stakeholder model. J Cancer Prev Curr Res. 2022;13(4):94-96. DOI: 10.15406/jcpcr.2022.13.00495

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Abstract

Purpose: To quantitatively evaluate the radiation safety culture in radiation medicine practice with Temporal-Spatial Decomposition Binary Equal Weight Stakeholder Model.

Method and materials: A radiotherapy treatment procedure was decomposed based on Temporal-Spatial information by combination of different stakeholders which are physician, physicist, dosimetrist, therapist, nurses, patient, administrator and others. The procedure included three steps, which were simulation, treatment planning and dose delivery. And each step included different radiation safety control corresponding to patient, radiation worker and general public in different levels. The radiation safety culture traits could generate outcomes at different safety level and display in the binary format for the success of the process. Each stakeholder’s weight in different radiation safety level would contribute to the overall score of the radiation safety level to patient, staff and general public. These quantified information were computed and optimized based on the decomposition function, which was represented by the product score and sums score determined by the temporal characteristics of the clinical procedure.

Results: Given the maximum number of safety culture trait at 9, two combinations of number of stakeholders and safety culture traits were calculated in simulation, treatment planning and dose delivery processes. For combination of maximum number of stakeholders and maximum number of traits, product scores were 3720087, 729 and 729; and sum scores were 72, 72, and 72; for minimum number of stakeholders and minimum number of traits, the product scores were 1, 1, and 1, and sum scores were 3, 3, and 3.

Conclusions: A simplified stakeholder model based on the temporal-spatial decomposed function was developed in describing radiotherapy treatment with the number of team members and culture traits implemented in binary mode.  And this quantified methods of clinical procedures using radioactive materials and equipment provides potential for computer evaluation of complex clinical practice system.

Keywords: radiation safety culture, radiotherapy, clinical procedure, binary model

Introduction

Since the discovery of the radiation,1,2 the utilizations of the radiation have been benefited our society in different industries such as energy, medicine and society security. However, the side effect of radiation had also being recognized gradually with the improvement understanding the characteristics of the ionizing radiation. As a consequence, the safety of radiation worker, general public and patient is crucial in the environment of radiation medicine practice. After several unexpected disasters such as the 1986 nuclear accident at the Chernobyl nuclear power plant in the Ukraine3 for energy generation and some incident in High Dose Rate brachytherapy in medical practice,4 the U.S. Nuclear Regulatory Commission (USNRC) had recognized the important of building positive radiation safety culture including nine traits,5 which are leadership safety values and actions, problem identification and resolution, personal accountability, work processes, continuous learning, environment for raising concerns, effective safety communication, respectful work environment, and questioning  attitude.  Besides USNRC, the radiation safety issue also had been addressed by different organizations such as in energy application such as The International Atomic Energy Agency,6   safety in radiation medical practice such as AAPM.7,8

The positive radiation safety culture depends on the complexity and the function of the organization. The high level safety culture includes assessment and improvement or optimization methodology. And it is benefit to provide a system for evaluation, education and communication with different professionals, therefore, based on radiation safety culture policy statement issued by the U.S. Nuclear Regulatory Commission (NRC), a time-spatial decomposition binary stakeholder modal based on radiation safety culture traits was quantified for the implementation to radiation oncology routine practice for operation simulation and radiation safety training.

Material and methods

A Radiotherapy Treatment Procedure was decomposed based on Time-Spatial information by combination of different stakeholders in each step. Each treatment time follows the time sequence of different steps during the procedure. The procedure includes simulation, treatment planning, and treatment plan dose delivery, which was shown in Figure 1.

Figure 1 A routine clinical procedure cycle in a radiotherapy department.

Each step have different time-spatial-radiation safety related factors and corresponding stakeholders, which are physician, physicist, dosimetrist, therapist, nurses, patient, administrator and others. Each step includes different radiation safety control corresponding to patient, radiation worker and general public in different levels. For example, during simulation process, a CT simulator is usually applied, the radiation dose to patient, radiation workers, visitor around the CT room and so on. The radiation safety culture traits could generate different safety level outcome and most of time in the format of the success of the process. Technically speaking, scenarios such as scanned the wrong position of the patient, used the wrong protocol or so on.  Each stakeholder’s weight in different radiation safety level will contribute to the overall score of the radiation safety level to patient, staff and general public. These quantified information could be computed and optimized based on the decomposition function. Figure 2 shows the number of traits and related stakeholders used for this quantitative operation simulation.

Figure 2 A stakeholder decomposition based on a clinical procedure cycle in radiotherapy department.

The quantitative value of the radiation safety culture practice could be computed with different methods, depending on the structure of the clinical procedure. In this study, the product score and sums score were selected due to the characteristics of the clinical procedure and related stakeholders. The temporal characteristics of the clinical procedure determined the series structures by different processes, which are corresponding to a temporal point.

When tasks in a process were executed simultaneously, the team members or stakeholders could be in different locations, so the quantitative value could be better described by sum score. Mathematically, a sum score could be expressed as following formula:

  1. Individual member m with  traits value Vm  based on sum score

V m ==f(t)=F( T i m )= i=1 N T i m MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqkY=Mj0xXdbba91rFfpec8Eeeu0xXdbba9frFj0=OqFf ea0dXdd9vqaq=JfrVkFHe9pgea0dXdar=Jb9hs0dXdbPYxe9vr0=vr 0=vqpWqaaeaabiGaciaacaqabeaadaqaaqaaaOqaaiaadAfadaahaa Wcbeqaaiaad2gaaaGccqGH9aqpcqGH9aqpcaWGMbGaaiikaiaadsha caGGPaGaeyypa0JaamOraiaacIcacaWGubWaa0baaSqaaiaadMgaae aacaWGTbaaaOGaaiykaiabg2da9maaqahabaGaamivamaaDaaaleaa caWGPbaabaGaamyBaaaaaeaacaWGPbGaeyypa0JaaGymaaqaaiaad6 eaa0GaeyyeIuoaaaa@4E1A@   (S_1)

Where, for member m, and culture trait tmÎ[0,1] for the value is treated as a continuous function; culture trait Ti m is 0 or 1, when binary approximation is applied. And N is total number of culture traits T. 

  1. Team g with traits value Vg  with group weight Wg  based  sum score

V g =f( w g , t g )=F( W m g , T m g )= m=1 M ( W m g × T m g ) = m=1 M ( W m g × i=1 N T mi g ) MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaam4zaaaakiabg2da9iaadAgacaGGOaGaam4DamaaCaaa leqabaGaam4zaaaakiaacYcacaWG0bWaaWbaaSqabeaacaWGNbaaaO Gaaiykaiabg2da9iaadAeacaGGOaGaam4vamaaDaaaleaacaWGTbaa baGaam4zaaaakiaacYcacaWGubWaa0baaSqaaiaad2gaaeaacaWGNb aaaOGaaiykaiabg2da9maaqahabaGaaiikaiaadEfadaqhaaWcbaGa amyBaaqaaiaadEgaaaGccqGHxdaTcaWGubWaa0baaSqaaiaad2gaae aacaWGNbaaaOGaaiykaaWcbaGaamyBaiabg2da9iaaigdaaeaacaWG nbaaniabggHiLdGccqGH9aqpdaaeWbqaaiaacIcacaWGxbWaa0baaS qaaiaad2gaaeaacaWGNbaaaOGaey41aq7aaabCaeaacaWGubWaa0ba aSqaaiaad2gacaWGPbaabaGaam4zaaaaaeaacaWGPbGaeyypa0JaaG ymaaqaaiaad6eaa0GaeyyeIuoaaSqaaiaad2gacqGH9aqpcaaIXaaa baGaamytaaqdcqGHris5aOGaaiykaaaa@70CB@   (S_2)

When Vg is treated as continuous function, weight  represents the weight of member m at group g.  Low case t and capital case T represent the continuous and discrete culture traits. M is total number of in group g, and N is total number of culture trait implemented by a member m.

  1. Radiation medicine procedure P with traits value Vp  sum score

V p =f( w p , t p )=F( W g p , T g p )= g=1 G ( W g p × T g p ) = g=1 G ( W g p × m=1 M T gm p )= g=1 G ( W g p ×( m=1 M W gm p × ( i=1 N T gmi p )) MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaamiCaaaakiabg2da9iaadAgacaGGOaGaam4DamaaCaaa leqabaGaamiCaaaakiaacYcacaWG0bWaaWbaaSqabeaacaWGWbaaaO Gaaiykaiabg2da9iaadAeacaGGOaGaam4vamaaDaaaleaacaWGNbaa baGaamiCaaaakiaacYcacaWGubWaa0baaSqaaiaadEgaaeaacaWGWb aaaOGaaiykaiabg2da9maaqahabaGaaiikaiaadEfadaqhaaWcbaGa am4zaaqaaiaadchaaaGccqGHxdaTcaWGubWaa0baaSqaaiaadEgaae aacaWGWbaaaOGaaiykaaWcbaGaam4zaiabg2da9iaaigdaaeaacaWG hbaaniabggHiLdGccqGH9aqpdaaeWbqaaiaacIcacaWGxbWaa0baaS qaaiaadEgaaeaacaWGWbaaaOGaey41aq7aaabCaeaacaWGubWaa0ba aSqaaiaadEgacaWGTbaabaGaamiCaaaaaeaacaWGTbGaeyypa0JaaG ymaaqaaiaad2eaa0GaeyyeIuoaaSqaaiaadEgacqGH9aqpcaaIXaaa baGaam4raaqdcqGHris5aOGaaiykaiabg2da9maaqahabaGaaiikai aadEfadaqhaaWcbaGaam4zaaqaaiaadchaaaGccqGHxdaTcaGGOaWa aabCaeaacaWGxbWaa0baaSqaaiaadEgacaWGTbaabaGaamiCaaaaki abgEna0kaacIcadaaeWbqaaiaadsfadaqhaaWcbaGaam4zaiaad2ga caWGPbaabaGaamiCaaaaaeaacaWGPbGaeyypa0JaaGymaaqaaiaad6 eaa0GaeyyeIuoaaSqaaiaad2gacqGH9aqpcaaIXaaabaGaamytaaqd cqGHris5aaWcbaGaam4zaiabg2da9iaaigdaaeaacaWGhbaaniabgg HiLdGccaGGPaGaaiykaaaa@965F@   (S_3)

Where G is total number of group, M is total number of team. Other symbols are addressed at section a, and section b.

When tasks are distributed in different process, the practice team member and stakeholders could be in different locations at different temporal points. Therefore, the quantitative value could be better described by product score. Mathematically, a product score could be expressed as following formula:

  1. Individual product score

V m ==f(t)=F( T i m )= i=1 N T i m MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaamyBaaaakiabg2da9iabg2da9iaadAgacaGGOaGaamiD aiaacMcacqGH9aqpcaWGgbGaaiikaiaadsfadaqhaaWcbaGaamyAaa qaaiaad2gaaaGccaGGPaGaeyypa0ZaaebCaeaacaWGubWaa0baaSqa aiaadMgaaeaacaWGTbaaaaqaaiaadMgacqGH9aqpcaaIXaaabaGaam OtaaqdcqGHpis1aaaa@4CF1@    (P_1)

Where, for member m, continuous culture trait tmÎ[0, 1], and discrete culture trait Ti m is 0 or 1, and N is total number of culture trait.

  1. Team trait weight product score chain

V g =f( w g , t g )=F( W m g , T m g )= m=1 M ( W m g × T m g ) = m=1 M ( W m g × i=1 N T mi g ) MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaam4zaaaakiabg2da9iaadAgacaGGOaGaam4DamaaCaaa leqabaGaam4zaaaakiaacYcacaWG0bWaaWbaaSqabeaacaWGNbaaaO Gaaiykaiabg2da9iaadAeacaGGOaGaam4vamaaDaaaleaacaWGTbaa baGaam4zaaaakiaacYcacaWGubWaa0baaSqaaiaad2gaaeaacaWGNb aaaOGaaiykaiabg2da9maarahabaGaaiikaiaadEfadaqhaaWcbaGa amyBaaqaaiaadEgaaaGccqGHxdaTcaWGubWaa0baaSqaaiaad2gaae aacaWGNbaaaOGaaiykaaWcbaGaamyBaiabg2da9iaaigdaaeaacaWG nbaaniabg+GivdGccqGH9aqpdaqeWbqaaiaacIcacaWGxbWaa0baaS qaaiaad2gaaeaacaWGNbaaaOGaey41aq7aaebCaeaacaWGubWaa0ba aSqaaiaad2gacaWGPbaabaGaam4zaaaaaeaacaWGPbGaeyypa0JaaG ymaaqaaiaad6eaa0Gaey4dIunaaSqaaiaad2gacqGH9aqpcaaIXaaa baGaamytaaqdcqGHpis1aOGaaiykaaaa@7098@   (P_2)

In this formula, the symbol representations are the same as those address in formula (S_1), (S_2) and (S_3).

  1. Radiation medicine procedure culture trait product score

V p =f( w p , t p )=F( W g p , T g p )= g=1 G ( W g p × T g p ) = g=1 G ( W g p × m=1 M T gm p ) = g=1 G { W g p ×[ m=1 M ( i=1 N T gmi p )]} MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaamiCaaaakiabg2da9iaadAgacaGGOaGaam4DamaaCaaa leqabaGaamiCaaaakiaacYcacaWG0bWaaWbaaSqabeaacaWGWbaaaO Gaaiykaiabg2da9iaadAeacaGGOaGaam4vamaaDaaaleaacaWGNbaa baGaamiCaaaakiaacYcacaWGubWaa0baaSqaaiaadEgaaeaacaWGWb aaaOGaaiykaiabg2da9maarahabaGaaiikaiaadEfadaqhaaWcbaGa am4zaaqaaiaadchaaaGccqGHxdaTcaWGubWaa0baaSqaaiaadEgaae aacaWGWbaaaOGaaiykaaWcbaGaam4zaiabg2da9iaaigdaaeaacaWG hbaaniabg+GivdGccqGH9aqpdaqeWbqaaiaacIcacaWGxbWaa0baaS qaaiaadEgaaeaacaWGWbaaaOGaey41aq7aaebCaeaacaWGubWaa0ba aSqaaiaadEgacaWGTbaabaGaamiCaaaaaeaacaWGTbGaeyypa0JaaG ymaaqaaiaad2eaa0Gaey4dIunakiaacMcaaSqaaiaadEgacqGH9aqp caaIXaaabaGaam4raaqdcqGHpis1aOGaeyypa0ZaaebCaeaacaGG7b aaleaacaWGNbGaeyypa0JaaGymaaqaaiaadEeaa0Gaey4dIunakiaa dEfadaqhaaWcbaGaam4zaaqaaiaadchaaaGccqGHxdaTcaGGBbWaae bCaeaacaGGOaWaaebCaeaacaWGubWaa0baaSqaaiaadEgacaWGTbGa amyAaaqaaiaadchaaaaabaGaamyAaiabg2da9iaaigdaaeaacaWGob aaniabg+GivdaaleaacaWGTbGaeyypa0JaaGymaaqaaiaad2eaa0Ga ey4dIunakiaacMcacaGGDbGaaiyFaaaa@91CB@    (P_3)

In this formula, the symbol representations are the same as those address in formula (S_1), (S_2) and (S_3).

In practice reality, the following combination of sum and product score are plausible. In our operation simulation, the following formula was utilized;

V p =f( w p , t p )=F( W g p , T g p )= g=1 G ( W g p × T g p ) = g=1 G ( W g p × m=1 M T gm p )= g=1 G { W g p ×[ m=1 M ( i=1 N T gmi p )]} MathType@MTEF@5@5@+= feaagKart1ev2aaatCvAUfeBSjuyZL2yd9gzLbvyNv2CaerbuLwBLn hiov2DGi1BTfMBaeXatLxBI9gBaerbd9wDYLwzYbItLDharqqtubsr 4rNCHbGeaGqiVu0Je9sqqrpepC0xbbL8F4rqqrFfpeea0xe9Lq=Jc9 vqaqpepm0xbba9pwe9Q8fs0=yqaqpepae9pg0FirpepeKkFr0xfr=x fr=xb9adbaqaaeGaciGaaiaabeqaamaabaabaaGcbaGaamOvamaaCa aaleqabaGaamiCaaaakiabg2da9iaadAgacaGGOaGaam4DamaaCaaa leqabaGaamiCaaaakiaacYcacaWG0bWaaWbaaSqabeaacaWGWbaaaO Gaaiykaiabg2da9iaadAeacaGGOaGaam4vamaaDaaaleaacaWGNbaa baGaamiCaaaakiaacYcacaWGubWaa0baaSqaaiaadEgaaeaacaWGWb aaaOGaaiykaiabg2da9maaqahabaGaaiikaiaadEfadaqhaaWcbaGa am4zaaqaaiaadchaaaGccqGHxdaTcaWGubWaa0baaSqaaiaadEgaae aacaWGWbaaaOGaaiykaaWcbaGaam4zaiabg2da9iaaigdaaeaacaWG hbaaniabggHiLdGccqGH9aqpdaaeWbqaaiaacIcacaWGxbWaa0baaS qaaiaadEgaaeaacaWGWbaaaOGaey41aq7aaebCaeaacaWGubWaa0ba aSqaaiaadEgacaWGTbaabaGaamiCaaaaaeaacaWGTbGaeyypa0JaaG ymaaqaaiaad2eaa0Gaey4dIunaaSqaaiaadEgacqGH9aqpcaaIXaaa baGaam4raaqdcqGHris5aOGaaiykaiabg2da9maaqahabaGaai4Eai aadEfadaqhaaWcbaGaam4zaaqaaiaadchaaaGccqGHxdaTcaGGBbWa aebCaeaacaGGOaWaaabCaeaacaWGubWaa0baaSqaaiaadEgacaWGTb GaamyAaaqaaiaadchaaaaabaGaamyAaiabg2da9iaaigdaaeaacaWG obaaniabggHiLdaaleaacaWGTbGaeyypa0JaaGymaaqaaiaad2eaa0 Gaey4dIunaaSqaaiaadEgacqGH9aqpcaaIXaaabaGaam4raaqdcqGH ris5aOGaaiykaiaac2facaGG9baaaa@91FB@    (C_1)

Where the individual culture trait T is applied to sum score, the process traits were represented by product score, and the whole procedure was in the format of combination.

More generally, the formula addressed above could be expressed in the format or matrix give number of stakeholder m, number of team g, and number of process p.

To illustrate this quantification model, several simplifications were embedded. The procedure score was computed with maximum and minimum combination of the stakeholder team based on the number of member in the team and number of traits of individual number and their combinations. The structures for these combination war chain or links. So a sum score or product score were used to simulate these structures for quantification evaluation.

Results

A completed two dimensional combination structure in table 1. For simplification, the numerical computation of the simulation was only done on the following two situations:

Culture traits\Stakeholder

Minimum (Min) number of Stakeholders

Maximum (Max) number of Stakeholders

Minimum (Min) number of  traits

Min+Min (Sum)

Min+Max (Sum)

MinXMin (Product)

MinXMax (Product)

Maximum (Max) number of  traits

Max+Min (Sum)

Max+Max (Sum)

MinXMax (Product)

MaxXMax( Product)

Table 1 Basic combination of scores of stakeholders and radiation safety culture traits for quantitative computation

Equal Weight Binary model with 9 traits with combination of maximum number of stakeholders and maximum number of traits

The results are showed in figure 3.  For  the maximum number of team member with maximum number of trait for a Radiation treatment procedure was with product score is  3720087, 729 and 729;  and sum score is 72, 72, 72 in simulation, treatment planning and dose delivery procedure.

Figure 3 Scores based on maximum number of stakeholder and maximum number of radiation safety culture traits.

Equal Weight Binary model with 9 traits with combination of minimum number of stakeholders and minimum number of traits

When the procedure involved only minimum number of stakeholders and minimum number of culture traits, the scenario is similar to one professional represented the whole team. The computation result is showed in figure 4.

Figure 4 Scores based on minimum number of stakeholder and minimum number of radiation safety culture traits.

Discussion

A simplified stakeholder model based on the time-spatial decomposed function was used in monitoring the efficacy of radiation medicine treatment with the number of team member and culture traits. And this model provide a qualified optimization tool for evaluation the efficacy of radiation medicine practice. When social economic factors and other stakeholders are considered, this method could be implemented in other radiation safety related procedure or environment for optimal monitoring the quality of operation with computer-driven simulation for decision-making and provide data collecting mathematical model.

In practice, only quantitative score number is positive the radiation safety is operated normally. In binary mode, positive mode corresponding to 1, and negative mode means 0. Continuous practice in negative mode could result in mal-practice or radiation safety issue in certain time span. For empirical information, analysis of big data from different practice center could reach an efficacy of the practice pattern in targeting radiation safety department.

For implementation, a series structure and parallel stricture could be programmed with input interface of stakeholder and safety culture traits. The number of stakeholder and safety culture traits could change the sum score or product score value. Mathematically, it is possible to find an optimal score value. Other factors such as cost of each stakeholder, expense of the culture treat practice,  changes of stakeholders, and variation of culture features could further improve the usage of this stakeholder binary safety culture model.

Acknowledgments

None.

Conflicts of interest

Author declares that there is no conflict of interest.

References

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