[A Questionnaire Survey of Nuclear Medicine Incident Cases at National University Hospitals]

In this study, we investigated incidents related to nuclear medicine examinations that occurred in national university hospitals participating in Association of Radiological Technologists in National University (ARTNU). Specifically, we examined the profession responsible for the incidents, years of assignment to the nuclear medicine department, incident types, and the level of impact. Based on these results, we aimed to clarify the trends in incident occurrence and discuss potential preventive measures.

This survey targeted 18 facilities belonging to ARTNU that agreed to participate in the study. The study period spanned from April 1, 2012, to March 31, 2022, and all nuclear medicine-related incidents that occurred within this timeframe were collected. The collected items included the date and time of occurrence, type of examination, details of the incident, cause of occurrence, profession responsible, years of assignment to the nuclear medicine department, and incident impact level. Each facility entered information on a standardized Excel sheet. Based on the collected data, the number of incidents was aggregated by profession, years of assignment, incident type, and impact level, and the trends were analyzed.

In SPECT examinations, the most frequent incident category involved issues related to examination procedures (e.g., acquisition or processing), accounting for 95 cases, followed by 85 cases related to radiopharmaceutical administration; 79 cases involving patient falls, trauma, or vital sign changes; 47 cases related to equipment malfunction leading to examination interruption or delay; 43 cases related to radiopharmaceutical ordering; 13 cases related to pre-procedure; 13 cases involving equipment or item damage; and 12 cases associated with patient misidentification or personal information leakage. In PET examinations, the most frequent category involved incidents related to radiopharmaceutical administration and automatic dose injectors, with 72 cases, followed by 49 cases caused by equipment malfunction leading to examination interruption or delay; 47 cases related to examination procedures (e.g., acquisition or processing); 44 cases related to pre-procedure; 29 cases involving patient falls, trauma, or vital sign changes; 14 cases related to patient misidentification or personal information leakage; 12 cases involving radiopharmaceutical ordering; and 9 cases involving radiopharmaceutical synthesis.

We clarified trends in incidents occurring during nuclear medicine examinations performed in national university hospitals in Japan. A higher number of cases were observed among staff with shorter assignment periods in the nuclear medicine department, indicating that, in addition to increased vigilance, there is a need to strengthen a systematic, organization-wide educational framework for less experienced staff. These findings suggest the need for heightened attention during procedures and enhanced structured education, especially for less experienced staff members. Additionally, as high-impact incidents were also observed, the implementation of preventive measures to avoid serious events is considered essential.