医療事故情報収集等事業第29回報告書の公表について
Contents
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7. v
8. 2 4 1 3
9. 2
10. 2 4 3 2 4
11. 5
12. 1 1 7 1 8 1 9 2 0 2 1 2 2 2 3 1 114 1 296 1 266 1 440 1 895 2 182 2 483 272 273 273 272 273 272 273 151 155 179 123 169 521 316 283 300 285 272 427 578 609
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15. 101 C No 8
16. No 7 M R I
17. 1 7
18. 2 3 1 2 3 1 4 9 2 4 1 1 3 3 1 1 5 0 5 0
19. 2 PTP P TP
20. 1 2 7 1 4 2
21. A
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23. es 8 eR RA
24. 91 C hod M MR 1 RI MR I
25. J NSUF 155 2
26. 1 2 3 7 2 4 6
27. MR I 1 MRI 3 EN a
28. 5 10 No 19 15 4 1 5 6 2 0 6 No 1 9 2 2
29. MR I MR 1 American College of Radiology ACR The Joint Commission Sentinel Event Alert 7 112 126 2 7 3
30. DI V ee 133 2 S FF
31. 4 dB dt MR I MR 1 6
32. Nephrologic systemic fibrosis MR I MR TI
33. 3 2 2 5 2 1 3 2 3 3 1 6 1 1 3 7 7 6 0 6 1 5
34. No 9 MR I MR
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36. 1 2 1
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49. 1 6 1 0 2 4 1 1 3 3 1 2 4 2 2 4 2 1 9 2 19 No
50. 2 4 1 1 3 3 1 2 85 2 1 MR C TT MR
51. 2 2 2 5 2 6 5
52. MR 1 Sentinel Event Alert 5 4 5 4 1 3 1
53. MR MR MR I I 1
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70. 2O 12 4 2 http www med safe jp http www yakkyoku hiyari jcqhc or jp 9 2 0 1 2 2
71. MR I MR 1 NE 2 a MR 1 MR I
72. 2 9 2 4 1 3 6 7 2 4 1 3 No 6 2 No 6 4
73. 2011 10 2 Ca 7 8 9 15 7 2 0 1 1 2 T i
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75. 103 C No No 13 MR M R I
76. 2 5 2 5 MRI 7 13 Rr w EO N 20 GMR 1 i
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80. 2 4 3 3 1 5 4 2 2 4 141 2 3 Cr gt FF B80 2 2 4 PL 2
81. 2 4 4 2 2 6 2 5 3 1 0 162 3 4 10 MR I MR I PU 5Fr PU 6Fr 150kpa 21 7psi 10mL
82. 9 2 3 9 No 5 8
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84. No 1 MR I 98 2 No 2
85. No 1 0 MR I No 5 6 MR I No 6 2 4 MR I 110 2 MR I American College of Radiology A CR The Joint Commission Sentinel Event Alert
86. 2 2 50cm 16 35 16 45 M R I MR 1I MR I
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117. MR I MR I MR I MR I MR I MR I
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372. tient Safety Alerts 12 Canadian Patient Safety Institute cpsi icsp lospital Authority Risk Alerts Japan Australia Canada Denmarki Hong Kong England and Wales California Hospital Patient Safety Newsletters and Alerts European Union et MA United States Japan Japan Council for Quality Health Care Medical Safety Informaton United States of America Sentinel Event Alert Newsletter The Joint Commission 1 3 No 4 8 5 9 Failure to check oxygen remaining Failure to implement measures to preventmather to child transmissinn of Hepatitis B Wrong site surgery ight left nd Follow up Report Insufficient knowledge ofthe administratian status for warfarinpotassium and blood coagulability Medical SafetyInformation releasedin 2010 Specimen mix up atpathalogical diagnosis Accidental removal of the endatracheal trachenstomy tube when changing positions Medical Safety Information released from
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