運用醫療照護失效模式與效應分析（HFMEA）降低同位素治療病房放射性廢水異常事件發生風險

Using HFMEA to Reduce Incident Risk of Liquid Radioactive Waste from Radionuclide Therapy Ward

10.6332/ANMMI.202409_37(3).0001

林至群(Chih-Chun Lin)；湯淑雯(Shu-Wen Tang)；陳郁豔(Yu-Yen Chen)；邱藍儀(Lan-Yi Chiu)；張雁翔(Yen-Hsiang Chang)；徐健欽(Chien-Chin Hsu)；鄭如伶(Ju-Ling Cheng)

衰減槽 ； 醫療照護失效模式與效應分析 ； 放射性廢水 ； 同位素治療病房 ； Decay tank ； Healthcare Failure Mode and Effect Analysis (HFMEA) ； liquid radioactive waste ； radionuclide therapy ward

核子醫學暨分子影像雜誌

37卷3期（2024 / 09 / 01）

69 - 80

繁體中文;英文

背景：醫療照護失效模式與效應分析（Healthcare Failure Mode and Effect Analysis, HFMEA）是一種系統性方法針對醫療作業流程做全面性的風險評估，找出流程中潛在失效模式及其原因，以減少重大危害錯誤的發生。同位素治療病房的放射性廢水處理是輻射安全的重大議題，放射性廢水管道及衰減槽異常事件例如滲漏，可能導致輻射意外事件或中斷治療排程。本研究目的在運用HFMEA降低放射性廢水異常事件發生風險。材料與方法：HFMEA跨部門團隊由本院輻射防護委員會、核子醫學科、新陳代謝科、護理、工務、警衛、環管及安全衛生各相關單位組成，運用HFMEA方法收集流程資料，辨識潛在失效模式及其原因，對嚴重度及發生機率進行討論並評分危害指數，以決策樹分析是否進行行動對策改善，並完成改善對策以降低事件發生風險。結果：我們透過HFMEA辨識出8個失效模式和16個失效原因，並對其中5個失效模式和8個失效原因提出8項行動對策，包括：增加平日及緊急水位紀錄和現場查核作業、制定放射性廢水管道暨衰減槽區緊急應變處理程序、辦理緊急應變演練、規劃專業定期保養維護、增設衰減槽區外環境輻射偵檢器、增設衰減槽馬達區漏水感知器、持續維護舊衰減槽為備援、病人衛教與住院天數調整，行動對策完成後已將危害指數從36分降低至16分，降幅56%。結論：運用HFMEA能降低同位素治療病房放射性廢水異常事件發生的風險。

Background: Healthcare Failure Mode and Effect Analysis (HFMEA) is a systematic approach for proactive risk assessment of healthcare processes. It identifies and eliminates known or potential failure modes and associated causes. The collection, storage for decay, and disposal of liquid radioactive waste from the radionuclide therapy ward is an important issue. Incidents such as leakage of liquid radioactive waste from pipes or decay tanks can potentially lead to radiation incident and interrupt the service of radionuclide therapy. The aim of this study is to apply HFMEA to reduce the incident risk of liquid radioactive waste. Materials and Methods: A multidisciplinary team, comprising the Radiation Protection Committee, Departments of Nuclear Medicine, Metabolism, Nursing, Engineering, Security, Environmental Management, and Safety and Health, was organized. We created a process flow diagram, identified failure modes and causes, and conducted a hazard scoring matrix and decision tree analyses. We proposed necessary actions and completed the chosen actions to reduce the incident risk. Results: We identified 8 failure modes and 16 failure mode causes. After we conducted a hazard scoring matrix and decision tree analyses, 8 further actions were required for 5 failure modes and 8 failure modes causes. The proposing actions included daily and emergency inspection checklist, establishing response procedures for liquid radioactive waste incidents, conducting response exercises, implementing professional regular maintenance, installing environmental radiation detectors and water leakage sensors with remote monitoring and alarm system, maintaining old decay tanks for backup, enhancing patient education, and adjusting isolation days. After actions were completed, the hazard score was reduced from 36 to 16, a 56% reduction. Conclusion: The incident risk of liquid radioactive waste from radionuclide therapy ward could be reduced via HFMEA.