한국의학물리학회지:의학물리 (Progress in Medical Physics)

  • 제25권4호
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  • Pages.298-303
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  • 2014
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  • 2508-4445(pISSN)
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  • 2508-4453(eISSN)
한국의학물리학회 (Korean Society of Medical Physics)
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ROSIS 자료 기반 방사선 사고 사례 분석 : 경향과 빈도

Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency

  • 구지혜 (고려대학교 보건과학대학 방사선과학과) ;
  • 윤명근 (고려대학교 보건과학대학 바이오융합공학과) ;
  • 정원규 (강동경희대학교병원 방사선종양학과) ;
  • 김동욱 (강동경희대학교병원 방사선종양학과)
  • Koo, Jihye (Department of Radiologic Science, Korea University, College of Health Science, Korea University, College of Health Science) ;
  • Yoon, MyongGeun (Department of Bio-Convergence Engineering, Korea University, College of Health Science, Korea University, College of Health Science) ;
  • Chung, Won Kuu (Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong) ;
  • Kim, Dong Wook (Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong)
  • 투고 : 2014.11.06
  • 심사 : 2014.11.24
  • 발행 : 2014.12.30
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초록

방사선치료안전보고시스템(ROSIS)을 기반으로 방사선치료 중 발생하는 사고의 경향성 및 유형별 빈도를 살펴보고 빈발사고의 유형과 발생원인, 발견 방법에 따라 향후 사고 유발인자 제어방법 연구의 발전방향을 살펴보고자 한다. 이에 따라 본 연구에서는 2003년부터 2013년까지 최근 11년간 1163건에 달하는 ROSIS 사고 자료에 대하여 분석을 수행하였다. 분석을 위하여 치료법, 발견 시점, 발견 방법, 발견자의 직종 등으로 규격화한 후, 각 항목별로 분류 및 백분율화 하였다. 근접사고(Near Miss)를 포함한 1163건의 사고 사례에 대하여 외부방사선치료가 97%이고 근접방사선치료가 2%로 조사되었으며 그 외 기타로 1%가 분류되었다. 계획 선량이 잘못 전달된 사례가 44% (497건)에 달했고 이중 대부분을 차지하는 429건(86%)이 3회 분할치료이전에 발견되었고 13건의 경우는 11회 분할치료 이후에 발견된 것으로 조사되었다. 또한, 발견 시점은 다양하게 분포되는 것으로 조사되었는데, 약 42%가 환자 치료 중에 발견되었고 29%는 차트 검사 중에 발견되었다. 방사선 사고 발견빈도가 가장 높은 직업군은 치료실에서 근무하는 방사선사(53%)인 것으로 조사되었다. 1163건의 사고 사례 중에서 환자치료 이전에 오류를 발견한 경우가 24% (273건)로 조사 되어 대부분의 사고(70%, 813건)는 사고가 발생한 이후에 발견된 것으로 조사되었다. ROSIS 분석을 통해 획득한 이러한 경향은 한국의 경우에서도 크게 다르지 않을 것으로 사료되므로 사고 예방과 조기 발견을 위한 보다 다양하고 체계적인 연구가 필요할 것으로 예상된다.

In this study, we examine the trends and types of incidents frequently occur during radiation therapy by using the data from the radiation oncology safety information system (ROSIS), according to discovery method explores the development direction of future research accident cause factor control method. This study was carried out analysis of incident data in ROSIS nearly 1163 cases in last 11 years from 2003 to 2013. We categorized into treatment methods, found the time, discoverer of occupations and finding ways to analyze the data. Then, we calculate the percentage and the classification for each item. About 1163 cases of incident cases including the near miss cases, external radiation therapy, brachytherapy and other were 97%, 2% and 1%. In the case was improperly planned dose delivery was 44% (497 cases) which 429 cases (86%) was found before 3 fractions and 13 cases were found after 11 fractions. The investigation was found to be distributed in various a found times. Approximately 42% of found time was during treatment and 29% of patients were found the problem during inspection chart. Occupation to discover the most radiation accidents was the radiation therapist (53%) who works in treatment room. Among 1163 incidence cases, 24% cases were found the accident before the treatment, therefore most of accident were found after of during the treatment (70%, 813 cases). This trend is acquired through ROSIS analysis, is expected to be not significantly different in the case of Korea, so it is necessary more diverse and systematic research for the prevention and early detection by using the ROSIS data.

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참고문헌

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피인용 문헌

  1. Radiotherapy Risk Estimation Based on Expert Group Survey vol.7, pp.None, 2019, https://doi.org/10.3389/fphy.2019.00118