ヒューマンエラーやヒューマンファクターに起因すると考えられた事例（医療
Contents
1.2.
3.
4.
5.
6.
7. 62 67
8. 49 67
9. 60 67
10. 4 5mm 21
11. 740ml
12. 53 67
13. 56 67 2
14. 2
15. 58 67
16. 51 67
17. 3 55 67
18. 2
19. o
20. CV CV CV
21. 1 2 3 HDF 4 3
22. Ma 1
23. 2 2
24. 1 2 3 4 5
25. 1 1 B 3 2
26. ua 20 30 PTA
27. 2 3 SpO 2 60
28. 1 3 46 67 CV CV
29. 30 67 mg 1ICU 5L 2
30. 2 CT
31. CV CV CV
32. 2 2 2cm IC
33. X 20 19 1 19 1 X 2
34. Oo 42 67 MM A 3 PMDA No 41
35. re gan 7 3
36. i 4 6 0 1 8 ao
37. 1
38. 17 00 SpO2 CT 15 30 HR
39. 10 20 SpO2 80 10 32 10 35 SpO2
40. INVOS 7 1 0 Vf 3 DC J SC20 1 CT CT 8 67 EE ME
41. CT 1 C4 5 1 1 4 2
42. SPO2 96 97 NS Dr Dr Dr 34 FiO2 1009 SPO2 9096 SPO2 8896 15L SPO2 949 SPO2 859 Dr SPO2 7396 Dr HR 135 BP 228 108 SPO2 10096 9 CT X P
43. ISMAC 14 A CV B B B W 5 00 CV CV CV X P CV
44. 2 A 5mm
45. 10 1A 70 PCPS CT
46. 1 5cm 5mm 5mm 5mm 27mm SpO2 SpO2 100
47. 59 67 17
48. n 30 22 67
49. 31 67 2L SPO2 909 7096 3L SPO2 20mgIV
50. 1 2 1
51. 1 3 1 1 5 3 6 CV 5FU 14 5 FU
52. A SpO 2 87 2L SpO 2 97 9896 61 67
53. HR 15 30 CT 17 C B B C Sp02 C CT CT
54. J bag
55. ST 1 3 call CPR
56. PC SPO2 80 XP 1 ao CODMAN 10 V P IV P
57. 30mg 500mg 4ml h 13 10 110ml 13 27
58. X 1 2 3 1 3 2 5 67
59. 4 11 00 40g 106 62mmHg HR90 SpO2 80 FiO2 219 5096 5 13 30 1 6 15 10 HR120 130 HR70 80 200mg 2 7 24 00 HR130 14 540ml 8 0 30 SpO2 7996 FiO2 809 SpO2 969 9 Sp02 789
60. 1200ml 70 RCC PC 41 67
61. 0 5ml H 5ml H 0 5ml H 5ml H 180 110
62. 2 A P P A 2 1
63. 50 67 102 0 CR ae MGS
64. RR 20ml h 15 18 10 17 67 JMS 18G
65. 2 0 8 1 67 LTV 10 10 15
66. PTGBD PICC 5 PTGBD CT CT PTGBD CT 1 2 1
67. 40 67 78 3 5
68. 64 67 19 40 MRI MRI 2 1 3 MRI MRI MRI MRI MRI
69. 2
70. 15 5mm 1 5 O 30
71. CV ME 47 67
72. air leak CT CT 38 67 IMT X P MT P MT 2 MT 0 MT
73. a Ei A 80 HR30 preshock CT HR30 80 200ml 100 CT CT
74. CV CT MRI DVT PE 7 5 2 60
75. 23G
76. CT 36 67 Sp02 70 CV
77. 2 2mm
78. 2 16Fr 39 67 0 CCU
79. CT 2 10 30 A B
80. 3 30ml 100ml H GI 3 5 2
81. 3 NE 0 9 SPO2 879
82. 2 ei 0
83. P PMDA TGBD No 36 3 PTGBD 5 CT 3 3
84. 200ml H 7 40 A A 1
85. 1 10cm 2 3 1 3 3 4 5
86. 2 4 5mm 24 Y 6F 24 6F Y 30 5cm 8F 35 5cm 8F Y 8F 2 94 100
87. ie 3L 1 i 7
88. OR lt 2 3 SpO2 209 SpO2 Sp02 FiO2 309
89. lt 14 50 CV BVM SpO2 70 SpO2 94 CV 15 CT 37 67 Ei
90. 50 A B 50 B B
91. 16 67 RE CT a 2 CT 3 100mg 19 5m 20ml 4 1 10 00 CV 2 3 10 20 4 11 10
92. 1A 3 0mm 33 67 CV 3 CT 4 30 CV CV X P 14
93. 14 40 15 30 19 40 CT
94. 3 DR RA 2 1 12 4 14 67 4 A 5 6 7 14
95. PCA PCA 20 4 13 40 14 10 14 20
96. 4 3 7 10 14 10 15 5 CPR 2 spo2 P
97. 11 12 9 13 9 1 lt 3 2 1 2
98. 2 5cm 8 1 20 15
99. 2 54 67
100. II 20 II 30 1 10
101. MRI Ua MRI MRI MRI MRI MRI MRI M RI MRI
102. 1 1 2 2 1 5 1 3 _ 2 3 2 4 ea 45cm 2 5
103. 3 6 00 7 30 14ml h 5R 9 67 in a RA OE 98
104. 3 7 8cm ICU 24 6F 6F 8F 18 67
105. CV OCT Oo 34 67 lee 18G CV CV XP
106. SPO2 12 25PEA PEA 4 i
107. pad 23 67 By 7 1 1 10 00 2 10cm 3
108. 0 85 1 2 1 3kg 48 67 16G
109. a Ei CPA CPA ICMV CO2 CO2 demand C MV 5 2
110. 11 67 8 25 9 15
111. 12 12 LTV Fi02 100 BP137 79mmHg 100 12 21 100 Fi02 30 12 24 Fi02 30 99 12 57 13 30 i i Fi02 27 100 70 150 100 lt 110mmHg 7 67 ee PCPS 8
112. 17 15 o 9 15 TE 161S 2 PTGBD 5 1
113. 100mL h 2 1 lt 2 3 OFF 3 0 2 3 0 5 CD 2 3
114. CT 2 1 AA B 3 B C D 2 1 C D 1 B
115. 19 3 4 5
116. 2 CV Oo 1 35 67 1 2
117. RAN DET ER 10
118. 11 35 15 20 GIF 2 GIF 3 EK
119. 52 67 CT CT CT
120. 1 1 1 PMDA No 36
121. X P P CONE 5 MT MT MT 10CM P
122. CV SMAC CV CV 45 67
123. 26 67 NEED IE 6 30
124. 6 3 VAPR 6 36L X 2
125. C C V 1 2 Sp02 80 ICU FiO2 100 X
126. B 2 20mL
127. mg T 15 40 0 70 100 14 44 50
128. 13 20 400 225 210 14 25
129. 30 7 00 ES 7 i in
130. 2 1 ME a 3 1 11 ED
131. 6 24 67 1 2 3 glc K7 8mEq L
132. CT 1 2 3 1 66 67 A B 2 A B A
133. CT CT CT 10 67 SCD ASO HD
134. CV CV 36 CV CV 1 W P CV X P CV CV
135. oO enterobactor 1000ml
136. CPK gt 2000 2 2
137. 1 1
138. CO2 9 2 2 CT
139. ED JMS 10Fr 4 0PDS 1 ED ED 16 15 A B CT ED ED
140. 44 67 PMDA No 36 0 9ml h
141. VAS 2 lt 3 10 60mg 750mg 4ml h VAS 2 10 28 67 11 2 THA PCA PCA
142. 3 4c m 7cm 1 4 CT 2
143. 6 PMDA 2 No 36 27 67
144. ED 7 10 2 1 2 100 21 67
145. 25 67 1 2 3 4 5 200ml h 30ml 48ml 14 10
146. A 4 67 ET
147. mw mm m
148. 2 67 alt 26 E 11 3
149. SM 2 6 X
150. gg 2 2 0ml h 2ml 2ml APTT40 1 1 0ml h 0 3ml h 15 0 5ml h 0 2ml h 0 4ml h 1 0ml h 60 1 CU 50 20ml
151. 1 ED 2 AS 3 ED 2 mg
152. 20 20 ICU T 14cm 5 CT 1 12 67 1 2mm
153. MRI MRI MRI 125 MRI 65 67 D
154. 20 4 2 O 1 1 CT SpO 2 95 room air 13 3 0 CT 57 67
155. 4 gt 4 V P 10 V P
156. 2 IC SpO02 20 U 15 46PEA HCU 4 15 47 1A 15 49 15 50
157. B A 10cm 100 C HR 28 1 11 JRE 15 50 90 11 50 11 57 6 0 BP81 44 mmHg 91 11 59 BP100 53 mmHg 51 12 03 BP102 66 mmHg 97 12 07
158. o 13 67 me a a Rh ET 2 14 15 1 ICU 7 10 30 1
159. SPO02 1 2 5 3 1 2 3 4 5 2 1 5
160. 36 2 3L min 1L min 15 3 67
161. SCD 2 Af SCD SCD 3INR 1 40 2 INR 3 20 2 4
162. We PTCD PTGBD 3 PICC 5 PTGBD 16 20 CT OT PTGBD 17 15CT 1 1 1 1 4 PTGBD
163. 15 30 16 00 CT 15 67 Ty EE
164. Hb8 8 7 7g dl MAP4 ENA 13 40 29 67
165. gt 3 gt ICU ME
166. OR RE 67 67
167. 20 67 2 Bu 8096 ao 3 3
168. 2 4
169. 500 5 4 7 56 1 SpO2 6 5 1 SpO2 90 6 5 7 CT 43 67
170. 2 15ml 3ml CT
171. 3 63 67 a MRI A
172. 5 1 6 67 1 X 2 I A RE 3 4 5 11 25 3 11 35
173. 30 IC 24 6 F Y 1 IC 1 00 1 2 PMDA No 32
174. MRI MRI MRI 30cm ES MRI MRI MRI
175. mg i 1 1cm x 1cm
176. ao 7
177. 2 32 67
178. ADL 1 2 1 3 2 9 00 4 9 55 5 3
179. 2 4 6 3 4 5 PCPS 8 00 16 00 16 30 4 10mL h 100mL h 15 23 38ml
180. 2 7 40 2 ME SpO2100 3 Sp02 3 7 50 4 Air 1 3 1 140 4 5
181. v MT P CRP 5 19 SPO2 1L MT 3 1 1 7 12 gt 1 1 2
182. 5 12 15 6 13 15 1 CV 2 1 2 3
183. CT SpO 2 PMDA SpO 2 CT No 36
184. OP OP 10cm PMDA No 41 1
185. CT 3 3 CT CT 1 2 3 1 1 14 40 BVM BVM BVM BVM
186. PIH 1 1 1mL h 10mL h 100mL h 10mL h 10 100mL 100mL 1 2
187. 3 A B C PMDA No 36 A
188. 2 25 30 ICU
189. ee plala A 3 3 60 Hb
190. 1 PT 7 ST UE
191. CT 19 67 2 8
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