MR 895 ノート MR 装置の安全管理に関する実態調査の報告思った以上に事故は起こっている圡井司 1) 山谷裕哉 2) 上山毅 3) 錦成郎 4) 5) 小倉明夫川光秀昭 6) 土橋俊男 7) 奥秋知幸 8) 松田豪 9) 10) 熊代正行論文受付 2011 年 4 月 19 日論文受理

Size: px

Start display at page:

Download "MR 895 ノート MR 装置の安全管理に関する実態調査の報告思った以上に事故は起こっている圡井司 1) 山谷裕哉 2) 上山毅 3) 錦成郎 4) 5) 小倉明夫川光秀昭 6) 土橋俊男 7) 奥秋知幸 8) 松田豪 9) 10) 熊代正行論文受付 2011 年 4 月 19 日論文受理"

そうとべ
5 years ago
Views:

1 MR 895 ノート MR 装置の安全管理に関する実態調査の報告思った以上に事故は起こっている圡井司 1) 山谷裕哉 2) 上山毅 3) 錦成郎 4) 5) 小倉明夫川光秀昭 6) 土橋俊男 7) 奥秋知幸 8) 松田豪 9) 10) 熊代正行論文受付 2011 年 4 月 19 日論文受理 2011 年 7 月 5 日 Code No ) 大阪大学医学部附属病院医療技術部 2) 奈良県立医科大学中央放射線部 3) 彩都友紘会病院画像診断部 4) 天理よろづ相談所病院放射線部 5) 京都市立病院放射線科 6) 神戸大学医学部附属病院医療技術部 7) 日本医科大学付属病院放射線科 8) 八重洲クリニック放射線科 9)GE ヘルスケアジャパン ( 株 ) 技術本部 MR 研究室 10) 倉敷中央病院放射線センター An Investigative Report Concerning Safety and Management in the Magnetic Resonance Environment: There Are More Accidents than Expected Tsukasa Doi, 1) Yuya Yamatani, 2) Tsuyoshi Ueyama, 3) Shigeo Nishiki, 4) Akio Ogura, 5) Hideaki Kawamitsu, 6) Toshio Tsuchihashi, 7) Tomoyuki Okuaki, 8) Tsuyoshi Matsuda, 9) and Masayuki Kumashiro 10) 1) Osaka University Hospital 2) Nara Medical University Hospital 3) Saito-Yukokai Hospital 4) Tenri Hospital 5) Kyoto City Hospital 6) Kobe University Hospital 7) Nihon Medical University Hospital 8) Medical Satellite Yaesu Clinic 9) GE Healthcare Japan 10) Kurashiki Central Hospital Received April 19, 2011; Revision accepted July 5, 2011; Code No. 261 Summary Using a questionnaire, we surveyed 2,500 facilities in Japan to clarify medical accidents concerning the magnetic resonance device and its environment. Data derived from 1,319 valid responses (52.8 ), allowed us to analyze the situation of (or the reason for) the occurrence of the accidents and their environmental factors. Five hundred and nine facilities (39 of all facilities) had the experience of magnetically induced displacement of the large ferromagnetic material. Intravenous (I.V.) drip stands were involved the largest number of them: 31 (228 cases). Oxygen bottles had the second largest number of incidents: 20. There were also many incidents involving various materials brought in by non-medical staff (e.g. stepladder for construction). About 20 of the accidents occurred outside of working hours. Patients in 12 of the facilities (154 facilities) experienced burns. In 39 of the cases, burns were received to the inside of the thighs. In 38 of the cases, patients received burns from an electrical cable touching the skin. There were also frequent incidents of burning regarding the boa. We received reports of burns and pain from the halo vest even though it s required to be worn for MR safety. Regarding incidents of contraindications, 280 patients with pacemakers were brought into the magnetic resonance (MR) inspection room. Twelve percent of the facilities experienced natural quench. Lack of training for the staff who introduce and operate high magnetic field devices are considered involving frequently occurring accidents of attractions and burns at hospitals with over 500 beds caused by carrying in materials. Key words: magnetic resonance device, medical accident, risk management, questionnaire survey, adverse event

2 896 緒言 1, 2 3) 4 5) magnetic resonance MR radio frequency RF 6 8) 2) MR ) 2010 MR MR 1. 方法 MR 2500 MR * MR 結果 MR : : : : : MR T T T T T 15 3 T 7 MR

3 MR 897 Fig. 1 Ratio of facilities which have had the experience of the attraction of large ferromagnetic materials according to the number of beds MR / / / / / Fig / Fig /737 Fig. 2 Classification of attracted large ferromagnetic materials /737 MR /737 MR /737 MR / /737 Fig /737 MR

898 Fig. 3 Classification of persons concerned in the accidents of the attraction. Fig. 4 Classification of the attracted ferromagnetic materials which belonged to the medical staff. Fig. 5 Classification of the attracted ferromagnetic materials which belonged to the patients.

4 898 Fig. 3 Classification of persons concerned in the accidents of the attraction. Fig. 4 Classification of the attracted ferromagnetic materials which belonged to the medical staff. Fig. 5 Classification of the attracted ferromagnetic materials which belonged to the patients : 458 : 435 : 362 : 172 : 134 : 113 Fig : 408 : 334 : 174 : 155 : 146 Fig

MR 899 a b Fig. 6 (a) Ratio of facilities which experienced patients who were burned, (b) Classification of the accidents according to the number of beds of each facility. Fig. 7 Causes of burns and injured regions.

5 MR 899 a b Fig. 6 (a) Ratio of facilities which experienced patients who were burned, (b) Classification of the accidents according to the number of beds of each facility. Fig. 7 Causes of burns and injured regions /1319 Fig. 6a : 0.6 1/ : 22 34/ : 33 51/ / Fig. 6b Fig Fig MR safety Fig : 12 : 10 : 8 : 7 : Fig. 10a

900 Fig. 8 Classification of the medical devices which gave pain to patients. Fig. 9 Causes of appeal for discontinuing the scanning by patients because of the intolerable nerve impulse they received.

6 900 Fig. 8 Classification of the medical devices which gave pain to patients. Fig. 9 Causes of appeal for discontinuing the scanning by patients because of the intolerable nerve impulse they received. a b Fig. 10 Ratio of facilities which allowed patients emergency call

7 MR 901 Fig. 11 Classification of contraindicated medical devices which were taken into the scanning room. a b Fig. 12 Check patients whether metals were attached to them. (a) Confirmers, (b) Check method Fig. 10b : 79 : 28 Fig. 11 MR Fig. 12a Fig. 12b 2-5 Fig. 13a Fig. 13b 3. 考察

8 902 a b Fig. 13 Experience of quenches. (a) Ratio of facilities which had the experience of the natural quench, (b) Timing of occurrence of natural quench Fig. 1 Fig MR Fig. 3 MR 10) MR MR Fig. 2 Fig. 13 MR Fig ) Fig

9 MR 903 Fig Fig. 6 12) Fig. 7 Fig. 8 MR Fig. 10b MR safety Fig MR 13) Fig. 13 MR ) *2 4. 結論 MR

10 904 MR MR 2011 MR 謝辞 22 参考文献 1 3T-MR 2008; 64(12): MRI 2004; 52(5): ; When thing go wrong : responding to adverse event To Adverse Events. pdf : 2009; 65(3): Och JG, Clarke GD, Sobol WT, et al. Acceptance testing of magnetic resonance imaging systems:report of AAPM nuclear magnetic resonance. Task Group No.6 Med Physics 1992; 19(1): National Electrical Manufacturers Association. Measurement procedure for time-varying gradient field db/dt for diagnostic magnetic resonance imaging systems NEMA Standard Publications MS National Electrical Manufacturers Association 1 Characterization of the specific absorption rate for magnetic resonance imaging systems NEMA Standard Publications MS MR MR 2009; 53: Chaljub G, Kramer LA, Johnson RF 3rd, et al. Projectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in MR suite. Am J Roentgenol 2001; 177(1): Kanal EMRI Q&A 1999; 19(7): MRI 2003; 59(12): IEC rd ED Medical electrical equipment-part 1: general requirements for basic safety and essential performance MRI 2008; 64(3): 図表の説明 Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 a b a b a b a b 67 8

52-2.indb

52-2.indb Jpn. J. Health Phys., 52 (2) 55 60 (2017) DOI: 10.5453/jhps.52.55 * 1 * 2 * 2 * 3 * 3 2016 10 28 2017 3 8 Enhancement of Knowledge on Radiation Risk Yukihiko KASAI,* 1 Hiromi KUDO,* 2 Masahiro HOSODA,*