医療ガスに関わるインシデント・アクシデント事例からみる再発防止の検討

抄録

The prevention of occurrence and recurrence of the incidents and accidents involving medical equipment is important in order to provide safe and quality medical care. Since medical gases that are used by medical professionals in the daily clinical setting are often compressed in cylinders, we assessed the incidents and accidents that occurred in relation to medical gases contained in cylinders in this study.
By using published data search on the Japan Council for Quality Health Care website, 102 cases that occurred in relation to medical gases contained in cylinders were extracted, and the causes of occurrences and methods to prevent recurrences were subsequently examined based on the occurrence summary.
The details of the occurrences included: not realizing that the oxygen cylinder had become empty, forgetting to open the valve of the cylinder, forgetting to set the gas flow, not being able to use the oxygen cylinder in an emergency, and damaging the flowmeter.
Multiple staff members from different occupations are involved in the usage of medical gases in cylinders, and the communication of information between medical professionals and between the patient, and error prevention through information sharing are extremely important to prevent the occurrence and recurrence of accidents.