資料2 ヒヤリ・ハット事例等収集結果 -医療機器-（PDF
Contents
1.2.
3.
4.
5. 5 0
6. 13 50 1
7. gt 50cm x 80cm
8. PI 7 61 EE a
9. A 2 7 2 C 1 B 3
10. o 10 15
11. ICU 1
12. VerSys 9
13. Cd 1 2 a 3 Yo
14. a o
15. 7
16. BA ME
17. 1 3cm
18. 5mm 4cm 5 CT I RE 5
19. 0 2 3 2 20 35
20. 2 3 1 16 61 VSD CHDF
21. 3 47 61 1 20 30 LTV950 1 2 3
22. 0 9 25 61
23. 2012 2 ee PICC as a M 1 CDDP 5 FU 4 5
24. 27 61 NN 50ml 100ml
25. 34 61 1 1 NE 2 2 A150 20G
26. X X X 2 Air leak 1
27. IABP ICU ME bronchofibe B 1 A 1 2
28. 1 2 3
29. 52 28 61 X XP X X
30. 3 136 4 0 0 0 12 8 84 4 93 68 49 8 31 22 8Y 0 136 100 1
31. 100mL SP 1 02 5 30 7 50 100ml 2 Spo2 2 9 30 SPO2 80
32. 14 BSM 8800 Dr 2 3 10
33. 1 5 9 50 B B C 1
34. 2 3 CO2 0 20 61 a a 10m H 1cm ETCO2 ICU
35. ICU 3 61 EE CV 10 FOLFIRI5 11 20 12 45
36. 3 A C
37. SPO2 SPO2 5896 10 2 3 26 PCPS PCPS 0 0 PCPS PCPS
38. 30 10 30 1 10 N G
39. 9 2 3cm
40. 24 61 24 Mb 2 2 12 SPO2 999 3 2 13 35
41. 3
42. 1 1 7 2 7 2 13 3 3
43. 4 38 9 35 61 CVC
44. SPO2859 8L SPO2 979 37 61 Sp02
45. 1 20 18 61 3 a sas
46. oo emem 50ml 1 TE 10 4 1 331S
47. EEE mr me
48. 14 61 ee NIP KK ake jm mm 6 1 7 40 2 1 2 3 1
49. 21 30 1 23 51
50. B X Y SpO2 99 X Y X C D D 13 30 X BP85 56mmHg P125 SpO02 98 lt 9996 O2 2L min 30 Hb 2 0 9 3 7 3
51. 29 CVC CVC 17 15 IC CVC U 70 80 40 lt 50 CVC mmHg 22 00 IABP
52. le 2 GE 7100 8 10 2 2 OFF ON 9 40
53. PH p DNR 2 2 3 PLT1 5 3 CV CV PICC 2 8 50
54. CV CV CV
55. 1 56 61 CV 2 ICU CV 3 1 30 270mg 2 5ml 1 20
56. 3 Oo 4 9 30 5 10 00 6 10 05 8Fr
57. 48 61 2 ON
58. 44 61 ICU ICU 12 55
59. 2 D 1 2 o 9 61 0 1 17 30 2 3 18 05
60. 23 5D 23 5D 23 5D 13 5D W 1 o 1 1
61. 18Fr 1 60 ASO ASO 3
62. 2 3 i RCA
63. 30 10 6 61 2 1 Y 2 2
64. ICU 45 61 a EEE 8 2 20 spo2 2 4m h 1 6O 100 10 O
65. 1 4 30 1 8 20 CT alb
66. a AR 13 61 RO
67. OD BE ED 13 30
68. 41 61 CT 2
69. 13Fr 14Fr 50ml 1 2 3 Ns 39 61 1 2
70. 5c CT ON
71. NG 1 2 o 5 N G
72. 1 32 61 a o CVC X
73. 43 61 2 2 3 2 1mm CV
74. 3 12 55 1 1
75. 2 CGM 2 3
76. NIPPV 10 1 PCPS IABP PCI 10 1 90 4
77. 2 2 3 4W 15 61 3 4 EE3 S
78. 3 R 4 R 0 5 0 5 1
79. 840 3 GUI 1 840 8
80. 8m 2 92 9396 2 3 2 17
81. 3 14 2 1 1 2 2 2 3 50
82. 1 2 3 AED ECG 4 5 6 7 8 9 10 11 12 2 3 8
83. 29 61 54 1 1 1 2 2 3 3 9 00 2 9 30
84. 104mmHg HR 132 38 CPAP FiO2 4596 PEEP 7cmH2O PS 20cmH2O 4 5 84mmHg HR 90 Paf SAT 3 596 SIMV FiO2 709 6 20 Pinsp 28cmH2O Tinsp 1 2cmH2O PEEP 6cmH2 O PS 20cmH2O
85. 12 43 AOT136 7cm 12 46 ACT116 ACT 12 58 ACT249 16 47 CV 16 48 CVC 17 48 CV 12G 20cm 18 10 CU SIMV 40 BP117 65 HR84 Hb10 2 18 45 CT
86. 6 PICC 6 10 A
87. 2 150ml PTBD
88. 3 40 SIRS 1 ICU
89. J 3 ESD 5
90. low dose FP 0 5ml hr 5m hr 1 46 61 5
91. 1 13 00 l ME CVC
92. 9596 1 200ml 200m 18 18 45 90 9596 12Fr
93. 20 15 CV XP CT CV CV
94. 2008 1 1 1 CV AC T Proximal 20cm
95. X P CT
96. AED
97. CV CV CV CV CV
98. ON ON AC
99. 4 1 3 49 61 BIPAP
100. B A 60mm 30
101. BiPAP GE 4 1 7100 RS es 1 1 1 Lu gt 2 3 N
102. A B PCPS A X B B C PCPS
103. 20 1 14 45 CV
104. 2 Were oo emem 3 A 1 1 1 O 1 A VT 3 VT 115 2
105. 0 4 61 CV X CV CV CV CV
106. 15 50 o 25 CV CV F CV SX 15G CV
107. 54 61 AI PCI
108. X 15 40 bak 18 19 X ARDS
109. 2 2 0 R 0 5 0 59 6 1 61 PS BE a AED AED MRI
110. 13 00 13 35 14 05 CT CV CV 5 CV VG
111. CNS CT CV 3 0 4 7 CV CV 2 2 ICU HCU High care unit 17 61
112. 0 Ns IDINR 3 23 61
113. 13 40 13 45 13 48 4cm 8cm 1cm 15 00 58 61
114. CV V 3A 40 A i
115. 42 61 6 1
116. ET NIPPV 4 ET O 2 2 3mm PCI 1 0mm
117. SPO2 1 AC MI
118. CV CV lt oO 23 5 25 0525 1 0525 1 23 5 25 0525 1 0525 1
119. CV 9 OR A DE Oe ICV
120. X P 10cm X P 12 1 X P X P 2 MCA X P 10cm 10cm 1 100ml 1 1 50ml 3 175ml
121. 1 1 ICU V 2 6 3 5 1 1 20
122. 1 2 xr _D 1 1 1 1 1
123. 2 NPPV NPPV NPPV 49 74 29 LAN NPPV 218 wire
124. 2006 2 5 1 1 2 3 2
125. 28
126. 2 7cm CV 2 8 5Fr 0 10 09 10 11 3 12 01 CV 1 2011 11 3
127. 5 2 ICU CT RDS
128. 6 13 39 4 0 Bp140 7 13 41 J vacDrain 8 14 20 Hb10 5 9 15 42 1705ml 10 16 10 Bp141 54mmhg P93 SPO2 98 ICU 11 OP Hb14 9 OP Hb10 6 Hb11 1 52 61 1 2 2 3
129. 2 3 25 AAI P 1 QRS QRS 3 25 VT110 115 min ICD 120 3 38 QRS AAI P 2 AAI P QRS 3
130. 3 1 5 OFF 8 4 BiPAP ICU OFF OFF
131. 12250mL OR 8 4 12 61 3
132. VT 1 4 30 A 2 2 3 12 CPR 14 CCU QRS
133. 625ml 3 3 H b4 8g dl Ht13 9 CT 1000ml RNN 30 61
134. 19 61 CPA CPA CPA
135. 3 A ECG ABP PAP CVP Sp02 SpO2 B C02 NR AS Sp02
136. NG 26 61 cn 8 1
137. 4 5 UE 1
138. 1 1 50 1 27 28 23 7 1 12 31 2 23 7 1 12 31 3 2
139. 8cm 1 1 i 1 1 1 3 2
140. 14 8 61 OJT
141. 1 12 55 I 18mm XP 2 8mm 9 00 0 30
142. 45 12 2 27 61 3 AED VFI Vf
143. 5 CT 2 CT PICC
144. A _ 2 3 15 00 5 1 5 4 3mm 5 6 2
145. 3 1 3 10 4 2 53 61 PK 2L
146. CV CV 11 17 CV CV CV 1 5cm 4 5cm
147. lt EN 2 BIPAP 3 BIPAP 4 BIPAP 5 6 BIPAP 1 30 7 8 BIPAP 9 BIPAP DNR
148. 4 HAS 90 18 43 100 40 2000 1 000
149. 2 IM SpO2809 4 500ml 1 5 2
150. SpO2 8096 9 09 SpO2 1
151. ICU 5 50ml o 1 2 2 3 5 RE EAR dy
152. 3 4 4 5 6 10 61
153. BIPAP 7 ICU ICU 8 BIPAP 50 61 S 5 ADU GOS CO2 SpO2 4mm CO2
154. Oo 11 20 26cmH2O 13 22 30 S 6
155. SonoSurg SonoSurg 1 1 1 2 2 2
156. 1 1 80 100 mmHg CVC 8 CVC 10 30 CVC CVC ICU CVC 90 mmHg 60 mmHg
157. 3 6 30cm Dr 40 61 StageIVB
158. 4 9 20 CVC 5 CV 9 50 10 50 CV
159. 1 BiPAP a 3 BiPAP SPO2 4 SPO2 1 BiPAP Y 2 Y 2 1 3 SPO2 6
160. x150mm 3 1 2 3 4 3 4
161. FFP CVC CVC 60 mmHg 110 mmHg CVC 15 ICU 9 CVC 3 2 36 61 1 PI 1 PI 4 27G 2 PI
162. IV CV IV IV IV 10cm CV
163. 2 2 B 2
164. 4 18 10 5 MA 6 SpO2 7 SpO2 1 1 2 2 3
165. EE 12 25G PI 1 3 PI 27G 7G 25G 4 46 3 PI PI lt
166. 2 g 5cm IgA
167. 8 SPO2 1 lt 23 50 HR1 20 130 SPO298 2 3 1 4 5 6 2 1 7
168. B B 1 C A 2 B B A 2 1 2 A 1
169. BIPAP 80 AS 2 RE 3 BIPAP 4 BIPAP SPO2 BIPAP 5 BIPAP 6
170. 1 5 61 1 1 ICV 6 7
171. PCPS X P X PCPS 13 CT PCPS 5 0 A B C CVC
172. 1 2 11 SPO2 B VM 3 BVM 3 4 18cm 1 5 50 2 6 3 6 2 My a 2 1 1 4 0 4
173. MRI AED VF AED VF AED 2 AED 30 11 20 1
174. 5 7cm 6 7 2 i CV BT ADL
175. 2010 4 2 60 61 25 EE
176. 2 30 3 21 3 10 15 4 22 30 31 61 16 40 19 OP OP 21
177. 90 30ml
178. 9 2 Sp02 O 7 61 3 GE 18 36
179. 4 EFT 6 4 14 17 35 SPO2 10L 18 00 CT CT 18 30 IN G 1
180. 15 2 19 4 a 1
181. 1 1 3 3
182. 3 4 34 789 41 0 22 19 3 1 3 1 ICD PC4 2 16 13 BIPAP2 CPAP1 11 61 IEEE Micro 4 4
183. 16 35 A SSI 12 R 0 5 83 2 R 0 5 3 1 PMDA No 15 R 83 0 59 2 0 5 B 0 59
184. 10Fr 779 959 6 1 7 40 1 5cm SpO02 999 8596 Sp02
185. GIA30 4 5 13 39 GIA3 0 1 2 3 4
186. o 3 20 40 4 5 20 45 SPO2 9796 6 20 47 SPO2 97 9896 116 54mmHg 130 721 28 2 16 18 8 21 30 ME IME 10
187. 30 500 260 500 2 2 AB B OJT A A 100 200
188. JMS SP amp 8722 500D O N 2cc 0 25mL 61 61
189. OD 3mm 1 8 58 2 2 GIA30 3 13 38 2 GIA30 2
190. 3 4 22 30 BIPAP 6 3 BIPAP SPO 2459 6 BIPAP 989 6 8 9 40 BIPAP HR50 SPO2
191. ME 2 ME ME 2 ME 1 2 2 3
192. 2 27 23 12 21 28 24 3 22 1 P 1 2 P 6 P 6 am P 47 3 P 48 24 8 31 24 1
193. 24 CHF NOR low dose FP 5 FU 5 FU 1250mg 15ml 5
194. SpO240 SpO2 1009 SpO2 22 61 Ea 23 40 SPO2 EN SPO258
195. 2L 18 3 9 2 7 30 200ml 15 38 61 2 1
196. CT CT 5 CT 4 5mg 21 20 CT
197. LR4 18 00 100mmHg X 33 61 67 14 25 9 12 40cm 10cm
198. 1 1 2 CV 3 ICU 4 5 II 4 PTBD
199. CT 17 CT 20 61
200. SPO2 4 SPO2 6296 5 24 6 13 40 10L SPO2 6796 13 45 SPO2 8596 13 50 SPO2 8896 X 13 57 SPO2 979 14 20 X 52
201. 5 3 7 6 05 8 9 4 21 61 1 oO 1
202. NG IC 6 20ml NG 9
203. 11 PTCD 59 61
204. lt 2 3 51 61 GE
205. oon mo 2
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