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. ADL 6 1 2 0 3 1 1 F2. 2 165 5 1 3 2 0 1 3
3. KA 64430 2 15 1 3
4. 2 0 2 3 1 1 0 0 1 2 0 3 1 1 2 3 3 7
5. 4 2 0 1 0 No 9 156 3
6. 161 4 1 3 1 1 3 2 0 1 3 5 e 1 6 1 7 1 9 3 9 3 9 BN 0 162 3 2
7. 26 1 2 http wwwmed safe jp 1 1 2 6 23 4
8. Lain 163
9. 1 7 23 4 1
10. 160 3 6 No 1 0 MR 1 8 1 MR 2 2 3 6 MR
11. 3 3 4 MR 1 2 RN OS BO 16 0 0 157 3 5 No 1 0 MR No 10 2007 9 Ro 10 2007 5 MRI TE MRI No 10 2007 9 DOI MR 8
12. 3 1 1 0 0 1 1 5 2 0 2 2 0 2 15 onHine available from http www nurse orjp nursing practtce anzen pdf 2011 20110307 pdf 1astaccessed 2011 07 07 2011 07 06 online available from http wwwJjaspa grjp news 080205 pdf ast accessed
13. 2 MR M R 1 MR 1 MR 1 159 i
14. MR MR MR I MR 1 MR 1 MR 1 2
15. 3 3 2 3 2 2 2 MR 1 2 2 2 EN 1 2 3 4 6 5 4 4
16. 1 5 1 0 1 0 1 1 1 2 1 3g 3000mg 1 3 3000mg 1 0 10 100mg 1 0 2 1 2
17. MR I 2 2 3 6 158 3 3 6 1 6 1 7 18 19 F 2 0 E 2 1 2 2 F 2 3 8 2 3 1 lt 6 3 2 3 6 RR 1
18. 1 HR SIR EOM DR RC PEELT UR 1 BER 5D0mg 4046 400mg7g 1250mg 125 OL AM 40 918Brmg 5 4 2 3 4 16 CA 1500m6 10 1 5g ID 1B00me 8
19. 153 3 1 23 4 6 EE 2 No 4 19 3 1 No 5 19 4 2 No 7 19 6 1 No 9 19 8 MR 2 No 10 19 9 3 No 14 20 1 No 15 20 2 No 17 20 4 2 No 19 20 6 1 No 23 20 10 2 No 27 21 2 10 1
20. 5 1 MR IT 2 MR MR I 3 1 MRI MR
21. 13 13 14 15 15 15 1 16 4 3 20 MR 1 22 23 24 154 E 3 4 2 No 9 1 No 9 1 9 8
22. No 1 0 MR 1 MR 2 MR 2 3 M R I 2 3 1 2 0 3 4 M R 1 MR 1 MR 1 2 3 6 MR 1
23. 4 4 26 26 26 26 84 108 109 130 131 140 141 152 3 26 153 166 LC 1 2 MR 1 3 N 9 26 155 156 No 10 26 157 181
24. ET TT TT TT TT MRI i U TOMO 7 MARI MR 2 8D04 10 007 931 SG Em NUE EMOTEAD ARS i 8 MT i YE 4 MD BE CL MRI MRI pt DEO 21 Prt ME REMAEEON ETAL TH TOME ARIELIRIE MOH MEER OREEM WL MRE TERARE CEL TRO TR ER hl OB ARE MEENTED Wei CNSIGEUEND Se 2
25. online available from http www bed anzen org pdf img 2151022 0001 pdf ast accessed 2011 07 06 166
26. A DL 164 3 1 I 2 1 4 RE 2010 7 8
27. 4 3 7 i 3 7 1 1 1 MR I 3 8 MR I 1 2 3 8 MR IN 5 MR T
28. 3 2 0 2 1 5 F 1 9 2 0 2 1 5
29. 3 MR No 10 1 No 1 0 1 9 9 MR I 2 1 6 1 0 1 9 3 1 8 2 3 2 3 4 6 2 3 4
30. 6 3 7 23 10 11 26 23 9 28 0928 2 0928 2 0928 2 0928 2 38 9 28 26 16 10
31. 13 i 26 162 166 http www med safe jp 2 3 3 Ry 1 2 3 4 6 1 8 3 1
32. 3 3 3 2 3 4 6 6 3 3 1 MR I
33. No 29 21 4 2 No 30 21 5 1 No 33 21 8 3 No 39 22 2 0 3 No 47 22 10 1 No 51 23 2 3 5 6 9 1 11 3 11 4 11
34. 4 2 2 2 3 2 1 6 1 0 9 1 9 3 1 8 4 2 1 1 No9 2007 6 No 9 2007 8 4 8004 10 1 007 3 31 9 R 40 6 1 125 mg DP 4 BMB 3 JH500mg 1250x0 4 oem OE 1250mg 9 T11250mg PA 3 5125mg 1250 04 END 9 2 B 8 gt 10Eo 10F 155 lt 2
35. 5 1 0 3 1 2 3
36. i kK LT ing 46 MG TU 160Omi WCDMAR SI KAY RIE IT EA CREE A ENE TKSA RE A ORLTE NAD WRT A FAORR TE TR ORE RENO TA OMRON TAM LN ESAT AE bpttiehcoriphimtost wt mdcet ate REREAD DERM EME TUT EL RTI TON St 4 WEIR ME OR REMRLI RE OE RAMEE UR 1101 0002 EINEFREEMDIRARS TT EEN EARP RE 038817 0252 Mg FAX 09 5817 0253 W toylghg peinmimrgac on No9 2007 8 e 2 10 3g 1 3 1 300mg 1 3 5 1 5 1 g 1000mg
37. 6 1 2 23 3 23 4 6 4 5 6 134 145 351 630 4 2 24 19 14 4 26 1 248 39 4 44 7 0 630 100 0 26 40 31 34 2 23 4 6 1 1 037 571 2 26 56 62 164 199 463 7 992 84 2 1 2 3
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