ヒヤリロハット事例等収集結果 ― 医療機器 ―
Contents
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9. No 1
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12. 1 32 61
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33. 5 2008 02 30 1 20
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53. 2 oeo INE P1 3 P4 10 P11 18 P19 31
54. 5 SpO2 40 5 6 16 SpO2 7 SpO2 AO 10 61
55. 1 2 2 2 2 3 1 3
56. SPO2 SPO2 58 10 2 3 26 PCPS 0 0 PCPS PCPS o
57. PTPE 4 1W 8 5 gt 6
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87. 2 3 2 Dr 10 A ECG ABP PAP CVP SpO2 SpO2
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93. OFF GE OFF 8 30 1 10 6 61
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96. 5mm 4cm 5 CT 5 3 faa o CT CT 5 OT
97. 8L SPO2 97 37 61 a oe mm Te 5 5 a 3 2
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107. PCPS lt 2 3 o 51 61 BE tt 21
108. 3 4 in vilro OR 1608 2 15 6mm in vitro AE pls LM 5 TN A 27 8 38 1 B 29 3 34 0 6
109. 2 60 61 RD mag V JMS SPg 8722 500D O 3A N 40 A 2cc
110. TE 1 1 1 1 1 Mr
111. 1 3 13 1 23 5D 4 W 13 5D W 1 4
112. 2 1 CT RDS 1 PTCD
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114. ee 16 10 10Fr 3 er 3 14 EFT 6 4 14 17 35 SPO2 10L 18 00 CT CT 18 30
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116. 10nL 10mL ve 28 1 1 2 3 4 9 9 1 11 13 14 6 X
117. A Ndi 3 Tl1 1 23 5D 23 5D 2 2
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119. X P 1 10cm X P X P 2 15 X P 50ml100ml 10cm
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121. 3 3 18 05 3 1 4 4 18 10 4
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123. 10 15 8cm 1 1
124. 6 BIPAP 1 BIPAP 1 30 4 BIPAP 7 HR50 SPO2 SPO2 BIPAP 8 BIPAP id N 9 BIPAP DNR BIPAP
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128. CV IV 3 2 1mm 10cm CV CV IV
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149. 2 3 13 14 2 21 30 1 23
150. PCI 10 2 1
151. k CT 17 CT 20
152. 5 9 0 CV 5 CVv 9 50 10 50 CV
153. 4 R 0 5 RY GIII 4 CM 5 5 i IAED VFI Vf AED AED MRI
154. NPPV 49 74 296 NIPPV LAN NPPV 218 o PK 2L 10
155. gt 172 32
156. 1 Y 2 2 Rs 9 40
157. 30 12250mL 8 4 12 61
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163. C 28 6 34 0 072 925 6548 7 1 2 3 4 5 6
164. nh a 1 LT 7 40 2 0 2 ME 1 2 13 2 ME
165. 1 20 18 61 RE o 5Ocm x 80cm CV cCV 11 17
166. 12 43 ACT136 7cm 12 46 ACT116 ACT 12 58 ACT249 16 47 CV 16 48 CVC 17 48 CV 12G 20cm 18 10 CU SIMV 4096 BP117 65 HR84 Hb10 2 18 45 CT
167. SPO2 12 1 4 SPO2 3 5 ee SPO2 6 6 4 BiPAP 4 1 ICU 3 OFF 1 596
168. 2 3 CO2 0 20 61 EEE cm mw yh Siti a 1cm ETCO2 ICU VM
169. Dr 40 61 0 Om mm Tm 0
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220. 12 55 18mm XP 2 8mm 9 00 0 30 1 2 3
221. PCPS X P X PCPS 13 CT PCPS 5 0 A B C CVC
222. 13 BIPAP SPO 4 BIPAP 13 BIPAP 2459 BiPAP 98 8 5 9 40
223. Cleaning amp Sterilization TPS CORE 5100 015 250 OR_5100 004 5400 050 000 CORE p gt OR 5100 010 050 5400 034 000 OR 5100 008 OR S100 050 5400 015 000 TPS OR 5100 009 1 1
224. 1 5cm SpO2 999 8596 Sp02 SpO240 Sp02 1009 SpO2 0 22 61 23 40 3 sisi
225. 1 2 3 25 AAI P 1 QRS QRS 3 25 VT110 115 min 1OD 120 3 38 QRS AAI P 2 AAI P
226. 2 24 61 Re 133 Wm mmm 24 ie 2 12 SPO2 99 3 2
227. 3 to ne a 4 1 8cm 1 5 50 1 4 0 11 2 6 4 5 2 3 2 3 4 5 3 AA 21 61
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232. ICV ICV CV 1 5cm 4 5cm
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238. 3 1 2 1 3 3 4 3 1 2
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240. 2 14 45 CV 15 50 CV CV
241. 8 1 4 5 6 6 2 1 7 Ns 2 SPA AA 23 61 0 E RUSH eee to LN i
242. X C D D 13 30 X BP85 56mmHg P125 SpO2 98 lt 9996 O2 2L min 30 18 00 100mmHg X Hb 2 0 9 3 7 3 LR4 33 61 mm 6 14 25
243. mm gt BIPAP 22 30 BIPAP 1 BIPAP BIPAP 6 3 12 BIPAP 1 12 BIPAP
244. 0525 1 CV CV CV 2012 2 NI
245. M gt gt X X
246. 3 23 6 24 5 6 20
247. 61 1 1
248. ECG 4 5 6 7 8 9 10 11 12 2 3 MC A 1 840 8
249. 1 2012 6 12 1 218008ZZ10117 51 16615200 SN 2 CV 20 ON 20 OFF 5 Ot Es EC Ee TI A 100 2
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251. of Vascular Comp icatibns Cansed by Central Yenous Catheters Ciin Monit 4 4 267 271 1033 14 Laster J and D Silver Heparin Coated Cetheters and Heparin Induced Thrombocytopenia J Vasc Surg 7 067 072 1988 15 Maschke S and H Rogove Cardiac Tanponade Associated with a Multilumen Central Venous Catheter Crit Care Med 12 611 613 1984 18 Nurray I P Complications of Invasive MOnitoring ed Instrumentation 15 2 85 89 1081 17 Peter amp J L Carreat Problems inCentral Yenons Catheter Systems Inensive Care Med B 205 208 1982 18 Putterwan C Central YenonsCatheterlsation Indications TechniGnes Compllcatlons Managenent Acute Care 12 3 4 219 284 1986 19 Puri vV K et a Complications of Vascular Catheterization in the Critically Ill Cr Care Med 8 9 495 499 1980 20 Bivers H et al Central Venans Oxygen Saturation Monitoring ia he Critically Ill patient Critical Care 2001 7 204 211 2L kivers E et al Early Goal Directed Therapy In the Treataent of Severe Sepsis and Septic Shock WE7A 2001 345 19 1368 77 22 Sise M J Complications of the Flow Directed Panlmonary Artery Catheter A Prospective Analysis 1n 219 Patients Crit Care Med 9 315 318 1981 33 Schwarts Fulton J etai Sepsis Related to Intravenous and Hyperallmentation Catheters A Summary of Recent Research Findings AM 74 4 243 255 1981 24 Tullio J Heparin Lock ar Continuous F
252. 0194000 12745002 30889000 13029001 35094114 13910000 95130002 70326000 32172011 15735000 16449000 13700000 13695000 34655000 70444000 11025000 12726020 10861002 35070002 31659200 1 300kPa 2 15N 4 NBLE
253. 1 45 2 2 2 61 57
254. 113001000 1 1 yl 5Ocm PVP 2 ey 3 2 2 73 E
255. 3 25 61 0 E oe ee me we ee ME bod CE le he 30 10 A 30 1 10
256. low ro 4 5 120 136 1980 25 Arnone M Central Venous Catheter Imsertion Assst im 44CCM Procedure Manmual for Crincal Care edition Lynn McHale Dj CerlsonKK eds 8B Saunders phliadeiphtm pgs 514 521 2001 26 Yenns 8 and Mallory L Vascular Cannuiatlom in Critical Care 2nd edition Civetta JL Kirby RR Taylor RY eds I B Lippincott Philadelphia pgs 149 166 1992 2 3 2 3 Yec 180 0023 6 10 1 03 6894 0500 Edwards 23 12 160 0028 6 10 1 03 6894 0500 Edwards Llfesciences LLC VCC CV X3820HSJD 3
257. nal Juguiar Yeln N Eng J Med 306 5 278 281 1982 3 Conahan T J et el Percutaneous Catheter Introduction The Seldinger Technique JAMA 237 440 447 1977 4Cook J D et el Erroneous Electrolyte Resalts Caused by Catheters Letter to the Edilor Clin Chem 54 1 211 1688 5S Csanky Treels Ff C Hazards of Centra Venous Pressure Monitoring Anesthesia 33 172 177 1078 bElliott C G et al Couplications of Pulmonary 5 6 15 Artery Catheterlzation jn the Care of the Criticaliy Ili Patient Chest 76 6 647 653 1979 Edwards H and T C King Cardjac Tawponade frog Centre Venous Catheters Arch Surg 117 065 967 1982 B amp Greene J F et al Septic Bndocarditisg and Indwelling Pulmonary Artery Catheters J4MA4 233 8 891 892 1975 9 oiden Aberrant Locations and Complications in Initial Plmcement of Subclavian Yein Catheters Arch Sg 119 3 203 205 1984 10 ibertl T J et al Hydrothorar as a Compllcaiion of Centr amp Venous Indwelling Catheters Surg 04 5 842 846 1983 li Jacobi J et al Loss of Nitroglycerin to Central Yenous Pressare Catheter Drug Intell Clin Pharm 16 331 382 1982 12 Jarred M M et sal The Effects of Antibiotic Ointments and Antiseptics on the Skin Flora Henesth Subclsvian CutheterDressings During Intravencus Hyperallmentatlon 7 Suwg Res 22 5 521 526 1977 13 Kapadis C B et al Delayed Recognition
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