医療事故情報収集等事業第 26回報告書の公表について
Contents
1. 156 3 3 MR No 10 1 No 1 0 1 9 9 MR 1 2 16 1 0 1 9 3 1 8 2 32. http wwwimed safe jp 26 1 1 23 4 6 1 2 23 4 6 mm 26 31 34 2 23 4 6 1 1 037 571 2 26 56 62 164 199 463 7 992 84
3. 460 3 6 No 1 0 MR 1 1 8 1 MR 1 2 2 3 MR 1
4. 161 4 1 3 1 1 3 2 0 1 3 1 6 1 7 1 9 3 9 3 9 1 7 1 8 19 2 2 2 3 162 3 2 1
5. 19 2 0 2 1 5 2 0 2 1 5
6. 2 3 3 7 A DL 164 3 1 4
7. 2010 7 8 2
8. 6 1 2 0 3 1 1 311001 2 2 0 2 1 5 3 2 0 2 NM 4 online available from http www nurse or jp nursing practice anzen _pdfZ2011 20110307 pdf ast accessed 2011 07 07 5 oniine available from h
9. 153 3 1 2 3 4 6 5 9 1 11 3 11 No 51 23 2 No 54 23 5 1 No 5 19 4 1 No 23 20 10 2 No 27 21 2 10
10. MR 1 159 II 4 3 7 3 7 A 1 MR 1 3 8 MR I 1 2
11. 2 3 4 6 2 3 4 3 4 MR 1 1 2 2 2 2 157 3 5 No 1 0 MR 1 No f0 2007 9 BR
12. 2 3 1 2 0 3 4 M R 1 MR I MR 1 2 3 6 MR 1 MR I 2 2 3 6 158 3 3 6
13. MR 1 MR 2 2 MR I M R MR I
14. MRI k EET RC MRI 3 I S MRI IK 13 i vx ERITH NE Rg py7jkohcor IEnMmed HONEY
15. 4 1 6 1 0 1 9 3 1 8 4 2 1 1 2 2 2 3 2 3 2 16 38 1SE NOB 2007 8 FM Ck 1 EE eNO H 1 258432 500 me TO No 9 2007 8 40 6 4 F 40 NT N 3 IRM3I 4 6
16. 3 8 MR 1 MR 5 1 MR I 2 MR I MR1I RE 3 MRI MR I
17. 163 I 2 0 2 3 1 1 0 0 1 2 0 3 1 1
18. 1 0 3 1 2 3 4 2 0 1 0 No 9
19. lt No 10 2007 9 MR b2 MRI M CMRI MRI MRI No 10 2007 9 SI MI 04 10 1 6007 9 9 9 2 HQ MRI
20. 7 23 4 1 RA NT RE AE
21. MI MRI p CANH 2r 3 GO63172oe W PAYio332122533CE rc pr Jp htm1ndexhtm 2 No 1 0 MR I MR I 2 MR I 2 3 M R I
22. 2 3 4 6 1 8 3 1 3 3 3 2 2 TMR I 2 2 2 2 2 1 2 3 4 6 5
23. 165 5 1 3 2 0 1 3 AD _
24. 26 40 2 1 26 84 108 2 26 109 130 3 26 131 140 4 EE 26 141 152 3 26 153 166 1
25. 4 4 3 3 3 2 4 6 3 3 1 MR I
26. 1 6 0 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 3 1 6 3 J 2 3 6 SS 1 MR MR 1 MR I MR I
27. KA 64430 2 15 1 3 3
28. 3 2004 W 3 E RI RR BIAS EE 150m 1 1O96 1 5g7 M10 1SOOrmg g sl me RR a OT R 409 1 125Dmg lt hw 3 ET piccork tat rgrmed ata 4 EE E34 Hou E500Omg 1250XD 4 oa
29. 1 0 1 1 1 2 1 3g 3000mg 1 3 3000mg 1 0 l 10 100mg 1 0 2 2
30. 1 125Hmg OPER WOT ER OR RUE RT ER TE EL RT OT DRL ORI2SOms SOGm 9125mwg 1250404 6 70 NJ 062 BT ERR ERRATIC TR lt gt 10 1Fe Oa Cae a FAK SOY EER OT 155 T 2 10 3g 1 3 1 300mg 1 3 5 1 5 1 g 1000mg 1 5 1 0
31. 1 No 29 21 4 Ne 51 No 54 tw 15 5 15 15 SS 0 3 20 16 MR 1 22 1 23 1 24 154 3 2 No 9 1 No 9 19 8
32. No 9 26 155 156 2 MR No 10 26 157 161 3 13 26 162 166 http www ned safe jp 3 _3 1
33. a ane 0928 2 0928 2 23 9 28 26 16 10 26 1 2
34. ttp wwwjaspa_grjp news 080205 pdf ast accessed 2011 07 06 6 Conline available from http www bed anzen org pdf tmg 2151022 0001 pdf last accessed 2011 7 06 166
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