CAJ | 학술논문

目的分析移动式直线加速器Mobetron实施术中放疗(IORT)中的潜在风险,初步探讨优化IORT各步骤的管理、减少潜在风险发生的可行性.方法由IORT团队(2名外科医生、2名放疗科医生、1名放疗物理师、1名放疗技术员、2名护士)应用失效模式和效果分析(FMEA)开展系统风险评估.确立流程模块,对每项模块分析潜在失效模式,对失效模式行频度(OR)、严重度(SR)、探测度(DR)评分,计算风险优先指数(RPN).结果 IORT流程分为9个模块,15项失效模式.OR最高值为激光软对位时间明显延长(8分),SR最高为Mobetron设备故障无法出束(10分),DR最高值为是剂量计算中发生的数据查询误差(8分),RPN最高为靶区确认不满意(198分)和未有效保护正常组织(180分).对每项失效模式均行原因和现行措施分析并提出预防措施.结论 FMEA是一种有效的IORT管理方法,有助于减少潜在风险发生.
목적 분석이동식직선가속기Mobetron실시술중방료(IORT)중적잠재풍험,초보탐토우화IORT각보취적관리、감소잠재풍험발생적가행성.방법 유IORT단대(2명외과의생、2명방료과의생、1명방료물리사、1명방료기술원、2명호사)응용실효모식화효과분석(FMEA)개전계통풍험평고.학립류정모괴,대매항모괴분석잠재실효모식,대실효모식행빈도(OR)、엄중도(SR)、탐측도(DR)평분,계산풍험우선지수(RPN).결과 IORT류정분위9개모괴,15항실효모식.OR최고치위격광연대위시간명현연장(8분),SR최고위Mobetron설비고장무법출속(10분),DR최고치위시제량계산중발생적수거사순오차(8분),RPN최고위파구학인불만의(198분)화미유효보호정상조직(180분).대매항실효모식균행원인화현행조시분석병제출예방조시.결론 FMEA시일충유효적IORT관리방법,유조우감소잠재풍험발생.
Objective To analysis of the various potential risks during the implementation of intraoperative radiotherapy (IORT) using a mobile linear accelerator Mobetron.Explore to optimize the management of IORT steps to reduce the occurrence of potential risks.Methods Selected the two surgeons,two of radiation oncologists,a radiation physicist,a radiation technician and two nurses who have been working for a long term in IORT team,applied failure modes and effects analysis (FMEA) to carry out systematic risk assessment.Established process modules,detected potential failure modes together with their causes and effects,scored to occurrence rating (OR),severity rating (SR),detection rating (DR),calculated risk priority number (RPN).Results IORT process is divided into 9 modules,15 potential failure modes.The highest OR was the prol nged time of laser soft-docking (8 points),the highest SR was the Mobetron equipment failed to output beams (10 points),the highest DR was the risk in the dose calculation (8 points),the highest RPNs were recognized as the target not covered satisfyingly (198 points)and not adequately protected normal tissues (180 points).For each failure mode,the existing measures were analysis,and preventive measures were proposed.Conclusions FMEA is an effective method of the management of intraoperative radiotherapy,to help reduce the occurrence of the potential risk in the IORT.