医療事故情報収集等事業 第27 回報告書
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236. 1 2 5 6 12 ge Japan Council for Quality Health Care No 11 October 2007 Blood transfusion to wrong Datient There have been eight reports of blood transfusions to wrong patients nformation collection period from October 1 2004 to June 30 2007 the information is partly included in Medical Adverse Event Information to Be Shared in the 9th Quarterly Report Six of the cases reported were cases in which the blood product to be used on the patient was not finally checked when connecting blood product for transfusion use In five out of six reported cases the blood product used for transfusion was checked with the ransfusion sheet or medical chart etc at the nurse s station but the blood product was notchecked againstthe patient Meacusgmy smaton Pakcti calect Medtoa Nasr M Adverse Evert nomator Ne 11 Octab r 2007 Blood transfusion to wrong patient Case 1 The physician ordered a blood transfusion to be given to Patient A The nurse pertormed a check of the blood product
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369. anization SN ES Accreditation E U EU 2 The Thai experience implementing WHO recommended measure for adverse events Accreditation program Kittinan Anankamanee 2008 The Institute of Hospital Quality Improvement amp Accreditation of the Ministry of Public Health The Hospital Accreditation HA program 2 WHO
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371. ion 2009 Annual Report Project to Collect and Analyze Pharmaceutical Near Miss Event Information 2009 Annual Report August 31 2010 October 5 2010 Japan Council for Quality Health Care Division of Adverse Event Prevention Japan Council for Quality Health Care Division of Adverse Event Prevention 2 1 2 1 6 The International Society for Quality in Health Care ISQua 2 8 The International Society for Quality in Health Care SQua ISQua 9 1 3 1 5
372. o 9 2 2
373. or transfusion use against the patient s name and blood type on the card at the nurse s station with another nurse The nurse then went to the bedside of Patient B and connected the blood product without checking if the Patient was Patient A Two hours latec the physician went to the bedside of Patient B and found unordered blood product was connected Case 2 The physiclan was caled away for another patients treatment while preparing the blood product for transfusion to 2 patients Patient C and Patient D Thirty minutes later the Physician moved to perform the transfusion to Patient C placed blood product for transfusion to Patient D in the tray went to Patent C s room and connected the blood product for transfusion without checking If it Was for Patient C Later the noticed that he had connected Patient D s transfusion blood product to Patient C because Patient C s was stil left unconnected Adhere to the hospital s blood transfusion manual and perform final checks of the patient and the blood product to be used when connecting blood product for transfusion use eapanaihil Division of Adverse Event Prevention Japan Council for Quality Health Care 1 JAPAN et Hp ju 1 3 Project to Collect Medical Near miss Adverse Event Informat
374. th f 1 Web
375. ty Health Care Medical Safety Information United States of America California Hospital Patient Safety e Newsletters and Alerts Organization The Joint Commission Sentinel Event Alert Newsletter 8 8 22 9 f
376. y Alerts 3 ee 7
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