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Contents
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7. 4 3
8. 9
9. 4
10. 3
11. f 2 FC
12. CN pir A
13. lt gt
14. 54 6 ETA Event Tree Analysis ETA
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16. a ul 1
17. 3 EC 58 2007 11 509 0261 4 3 3
18. E Institute of Medicine Committee on Quality of Health Care in America
19. O
20. 48
21. 1 2
22. BB 0 20 40 60 80 100 43 5
23. RS MM A H
24. 25 gt B E
25. Medical SAFER 7 1 2 3 4 5 55 I Tn rt
26. 16 2 5 11 6 85 81 4 3 7 0 8 17
27. SHEL 4M 4E FTA FMEA Medical 50 1 SHEL m SHEL P mSHELL SHEL 1972 Edwards
28. ie 1 5 a
29. 2 FTA 1 2 3
30. 5 HU
31. E 1 SR 11 2 44 1 D 4 O 84 2006 3 1
32. ul A JAL907 2007 1 23 IFALPA
33. 14 IN gt 2
34. 17 PDF Ch UN gt
35. 1 E 1 YES 0 5 1 TT gt NO
36. 6 21 8
37. 14 3 F
38. gt 7 gt I
39. ts 40 60 80 100 9 6 2 52 9 1 8 3
40. 4 a 4 NM NN NE
41. ke 1 L Kohn J Corrigan M Donaldson Institute of Medicine 2000 To Err Is Human Building a Safer Health System National Academies Press 2 2002 0830001 http www mhlw go jp topics bukyoku isei anzen 2 kaise index html 3 2002 1007003 http www mhlwr go p topics bukyoku ise7 anzen 2 kaiserindex html 4 2004 http www mhlw go jp topics 7bukyo
42. 40 6 50 0 1 8 3 4 33 3 2 16 7 11 35 5 2 6 5 1 3 2 8 25 8 4 12 9
43. Er a A ES Er
44. 5
45. 1 1 2 1 2 3 4 5 6 3
46. 1 2 7 7 Medical SAFER Sytematic Approach For Error Reduction Medical SAFER
47. k ul 4 1 1 7 8 r E
48. Q 4 5 SHEL M Management m SHEL 1994 m SHEL P Patient P mSHELL 3
49. ul gt R
50. gt a 2 1 o 3
51. 35 81 4 17 3 36 88 7 7 16 83 8 18
52. 1 EO 0 CR OE RA NN 0 AA
53. 1 gt
54. 4 47
55. 6 i 3 12 27 9 2 1 13 30 2 47 1 2 5 11 6 1 1 2 3 3 1020
56. 3 E 5 6 7 E
57. 6 6
58. EATCA 9 JAL706 H 3
59. gt 3 gt 3
60. 6 7 f 7 Check 8 Act
61. 2007 11 f 12 4 14 8 16 9
62. 20
63. 3 E
64. 3 IL ot ss PDCA Plan Do 5g
65. ks 4 49
66. 18 4 5 B 35 81 4 82 74 4 a A 19 44 2 i 27 9 Web 9 20 9 4 9 8
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68. lt 17
69. E f 5 EE 1 9 1 F
70. I FDA Med Watch Safety Ii 19 Web FDA MedWatch Safety 0 7 100 96 19 5 3 6 5 1
71. PDCA Plan Do Check Act 23 17 39 5 24 55 8 36 83 7 2 22 13 30 2
72. 4 gt 16 ei NNN oO gt
73. 2 9
74. 26 60 5 11 25 6 27 lt 12 27 9 26 27 4 8 18 6 14 32 6 7 16 83 12 27 9 24 55 8
75. H 1 9 9 2 3 5 6 E E 4
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77. JAL 2001 1 81 Ft a E 3 1 3 f V gt
78. 6 12 31 1 11 91 7 9 75 0 8
79. S Software H Hardware E Environment L Liveware 2 SHEL 51 2 SHEL 8 A B O B
80. 66 7 9 75 0 25 80 6 21 67 7 15 48 4 11 35 5 2 6 5 1 3 2 37
81. 1 1 43 jn 2
82. di 53 7 58 3 3 25 0 7 1 8 3 20 65 0
83. 6 36 1 3 4 13 2 1 6 18 5 1 1 2 2 1 2 3 1 2 4 1 2 3 4 5 5 1 2 3 ub 28 5
84. EB m SHEL 16 37 2 Root Cause MS 14 32 6 4M 4E 7 16 3 Medical Safer 5 11 6 4 9 3 2 4 7 KYT 1 FEMA P mSHELL 2 3 20 ta SHEL m SHEL 4M 4E Medical Safer 0 10 20 30 40 9 20 2
85. 3 4
86. top event 1 2 3 1
87. 1 3 17 2005 10 51 62 2 8 9 8 48 52 4 2 2
88. 4 7 58 3 11 35 5 6 3 41 6 3 42 0 20 40 60 80 100 9 41
89. 3 25 I
90. 32 27 0 ON 6 14 0 27 9 1 2 3 10 23 3 Re 2 4 7 6
91. 11 23 53 5 14 32 6 5 11 6 3 7 0 MS 3 i EC 7 0 11 25 6 22 51 2 8
92. 2 4 FT E ry
93. 83 26 2 3 4 7 25 58 1 32 4 7 2 3 2 3 33 2 16 37 2 19 44 2 4
94. D 7 10 11 1 12 13 14 15 16 17 18 19 0 22 23 2 x 24 3 25 26 27 28 9 31 3 3 34 35 0 7 8 36 7 8 39 161 41 42 43 _6 _8 _9 _ _10 _11 1 _12 13 14 _15 _16 17 18 119 22 23 24 25 _26 _ 27 _28 31 134 35 36 139 40 _42 143 41 lt 3 gt
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96. 5 3 16 6 Se CE 57
97. H 1 2 53 56 B
98. ME me gt 1 1 0 5 gt 2 5 4b
99. 1 29 800 12 2 1 3
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101. 17 54 8 25 80 6 27 87 1 13 41 9 20 64 5 10 32 83 21 67 7 20 64 5 18 58 1 10 32 3 4 12 9 7 22 6 8 9 7 8 9 7 9 29 0 15 48 4 fi n 12 n 31
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104. E Qr gt 9 gt WW
105. 1 2 16 19 6 10 39 J 1
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108. TEL 052 262 3028
109. FMEA 7 16 3 Medical Safer 3 7 0 4M 4E el MC i 21 i i 10 6 14 0 36 88 7 8 28 21 3
110. 21 1 37 4 35 I 1 1 2 3 4 2 25 14 2 1 2 3 4 3 1 2 3 4 27 12 1 2 ff
111. 4 11 8 11 32 4 1 2 9 18 52 9 2 1 36 883 7 30 69 8 23
112. n 12 n 31 0 20 40 60 80 100 9 6 87 2 12 28 6 1 18 31 0 1 2 5 11 9 1 1 2 4 9 21 4 8 25 8 1 10 32 3 1 2 4 12 9 7 22 6 1 5
113. 11 1 11 2 1 3 8 12 1 12 2 12 3 12 4 12 5 12 6 18 7 18 3 9
114. UA NE Oe ON OS I gt 6
115. 20 3 20 4 21 5 21 6 22 7 22 4 2 22 1 22 2 23 3 23 4 25 5 26 6
116. 42 1 8 8 9 3 9 7 23 74 2 43 7 58 3 9 29 0
117. 58 a x x x O x x x O O O x x
118. 2 3 RCA Root Cause Analysis Root cause analysis
119. 5 gt 6 gt
120. 1 FMEA 7 2 16 3 PDCA Plan Do Check Act 1 17 2 24 G 5 1 37 1 2 2
121. 9 5 1 1 2 34 79 1
122. C C 1 5 23 34
123. 1 O 2 3 x 7 EpucATion 2 O 1 2 ENGINEERING O NN IS 1 9 ES ENFORCEMENT 2
124. RM 2 gt
125. E 6 E RCA SAFER
126. 38 3 9 75 0 12 88 7 3 4 89 0 20 40 60 80 100 1 1 2 1 38 0 20 40 60 80 100
127. A 1 1 34 2 3 3 6 2 E 1 _ 12 2 10 3 21 Qr 3
128. Pi k 3
129. 12 11 2 23 3 58 5 34 79 1 86 88 7 17 39 5 15 34 9 3 7 0 25 58 1 12 27 9 2 4 7 29 67 4 10 28 65 1 23 3
130. 4 86 20 40 60 36 2
131. 90 10 28 3 1 13 30 2 1 0 6 1 10 10 3 3 1 25 58 1 _ 17 39 5
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135. 25 16 87 2 E 25 2 NI 25 58 1 Rh 12 27 9 Me 26 3
136. 4 11 EE RT RD
137. 12 38 7 4 0 20 40 60 80 100 96 47 7
138. 39 5 41 7 9 75 0 9 75 0 2 16 7 5 41 7 2 16 7 8 66 7 8 66 7 5 41 7 4 33 3 1 8 8 2 16 7 7 58 3 40
139. 1 1 26 2 17 2 1 5 2 35 3 3 4 0 36 3 1 36 29 7 4 5 32 35
140. a 15 25 12 29 28 23 17 14 3 5 7 2 3 3 3 3 3 8 cn EE 1 20 6 2 35 D 5
141. 28 5 002 6 14 0 10 23 3 21 48 8 29 EE 12 28 0 20 40 60 29 6 Ne 1 2 8 CE 30 7
142. 34 40 60 34 3 10 1 1 gt
143. 12 3 27 9 7 0 6 14 0 10 23 3 21 48 8 8 1 3 8 5 1999 1 8 3 2000 3 25 0 2001 E 1 8 3 2002 2 16 7 2003 2 16 7 2004 1 8 3 2005 2 16 7 2002
144. 27 70 4 0AzRBRNSSRththRhoNRNIEdhToeei 27 8 HKDR RTT 28 9 NG RES 29 1 gt 33 2 5 0 Oe 42 3 1 43 122caagasnoeoorimgeogossoszo 43 2 0 rd 45 17
145. QO me E ul 4
146. 0 20 40 60 80 100 96 46 ml 6 PDCA Plan Do Check Act 5 41 7 47
147. 1 2 3 4 9 8 32 74 49 ll 3 1 Du NN 3 1 Du SN 3 5 5 1 26 60 5 17 39 5 16
148. 16 2004 12 24 7
149. 3M
150. E 1 bh i A 3 tt FE 17 3 3 1
151. 2 3 IT 4 5 6 7 8 9 10 40 2 gt 50 No
152. 8 66 7 18 58 1 7 6 44 2 16 7 9 75 0 1 8 3 ON 3 9 7 6 er 26 83 9 CN 45
153. 35 Web 9 19 12 FDA MedWatch Safety 4 4 0 DO OO PR F 5 1 1 SHEL m SHEL 16 2 4M 4EE 3 RCA Root Cause Analysis 13 4 17 2
154. m 1
155. 1 1 a B 3 1 1 39 2 40 3 88 4 88 2 3 1 12 2 1 13 3 1 2 5 4 1 1 5 0 34
156. 6 6 YY Hy 34 79 1 ta 3 1999 3 8 8 2000 6 17 6 2001 2002 4 11 8 2003 7 20 6 2004 2005 5 14 7 2002 6 4 5 1999 I Rr 1999 4 6 3
157. A E Qr 2 14 2002 10 1007003 82 17 2005 10 5
158. D 1 nn 1 2 24 18 D 2 1 16 2 26 E D 3 1 2 4 3 32 4 1 19 2 21 ll E 5
159. 0 20 40 60 80 100 44 0 20 40 60 80 100 45 91 ni 11 91 7 25 80 6 9 8 46
160. 12 4 14 8 16 9 1 H 1
161. 1 2 83 6 14 0 18 41 9 8 18 6 24 22 3 7 1 24 0 3 8 1 28 53 5
162. 1 18 41 9 24 55 8 13 14 13 2 15 4 16 37 2 26 60 5
163. 43 52 4 1 84 79 1 NM 12 27 9 2 15 44 1 5 41 7 3 A IE 25 58 1 6 7 4 5 NN NN 36 85 7 4
164. 2 4M 4E NASA 4M 4E 4M 1 Man Machine 3 Media d Management 4 4E 1 Education Engineering 52 3 Enforcement 4 Examples 4 4M 4R 4 4 4M 4E 8 MAN MACHINE MEDIA MANAGEMENT
165. MURUA PO 4 9 83 85 006 31 37 86 0 30 35 81 4 31 3 9 1 25 58 1 14 82 6 2 4 7 1 2 8 6
166. 12 9 12 9 3 4 1 15 5
167. 1 4 2 11 3 1 4 18 B B 1 5 1 40 2 3 B 2 5 383
168. Root Cause Analysis 4 FTA Fault Tree Analysis FTA 1960 1960 53
169. 1 4 2
170. 82 17 2005 10 51 62 2 43 52 4 1 34 79 1 12 27 9 2 15 44 1 5 41 7 38 25 58 1 6 4 5 40 93 0 5
171. gt 40 93 0 1 _ 8 0 20 240 60 80 100 9 8 1 1 2 3 gt 4
172. 8 16 25 12 26 11 8 14 7 12 24 6 6 10 38 A 4 6 1 2 FB 7 1 2 8
173. 8 0 3
174. FH 8 8 66 7 15 48 4 49 40 60 80 100 96 49 8 66 7
175. 1975 KML Hawkins S Software H Hardware E Environment L Liveware L 2 SHEL L S H L E 2 CRM Crew Resource Management CRM 1970
176. 36 85 7 6 12 27 9 1 18 30 2 1 7 18 41 9 16 37 2 8 23 53 5 9 4 9 4 10 25 58 1 27 62 8
177. 2 FT AND OR 3 4 1 2 FT 3
178. RI 1O 1 1 1 2 3 P mSHELL 7 2002 P Patient S Software H Hardware L Liveware L L Liveware L
179. Y 2005 4 D 4 O 86 2006 5 ml 2004 57 44 6 2005 7 PmSHELL http www medicalsaga ne jp tepsys p mshell htm 8 5 2 9
180. 5 gs 4a 3b 3a O 2 1 0 46 2
181. 2 IN 5 35 40 60 80 100 96 35
182. 12 27 9 1 18 30 2 1 41 9 16 37 2 23 53 5 9 4 9 4 40 93 0 5 6 18 7 p 8 30 17 2
183. 3 4 3 6 1 2 3 3 7
184. 9 29 0 1 3 2 55 29 Ey 0 20 40 60 80 100 54 0 20 40 60 80 100 55
185. 4 To Err Is Human Building a Safer Health System 6 f E 14 2002 8 hi 0830001 EE
186. 5 FMEA Failure Mode and Effect Analysis FMEA FMEA HFMEA Health care FMEA FMEA
187. 51 Ti Ii 0 20 40 60 80 100 0 9 51 1 3 2 52 3 28
188. 3 9 7 53 10 83 3 2 16 7 15 48 4 12 RE 88 7 2 6 5 1 8 2 SE 1 54 0 20 40 60 80 100 06
189. 58 5 7 20 46 5 3 69 8 1 2 3 9 1 2 9 7 1 x 3 2 1 5
190. rrr 13 1 rere 13 2 rrr 14 3 10 14 1 14 2 oo 15 3 15 4 16 5 17 6 17 7 RR 17 8 18 9 18 OE 1 ORS RR EE hrs 19 RI 19 19 1 rrr 19 2
191. 17 54 8 50 2 0 20 40 eo 80 100 50 7 58 3 19 61 3
192. ku sesaku kojin d1 170805 11a pdf 392 1 gt
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