資料2 ヒヤリ・ハット事例等収集結果 –医療機器-（PDF
Contents
1.2. A A 90 lt 80
3. 2 5ml
4. 1 2 2
5. 2 ICU 3
6. 1009 4 0 A CVP
7. 3cc 5cc
8. SpO2 air SpO2
9. 62 77 41 2
10. 19 1 SpO2
11. CCU 2 BIPAP 13 00 BIPAP A 8 2 min
12. 4 77
13. 899 A
14. 46 60 839 GCS E1 VT M1 SIM 23 28 40 23 34 PEA 23 36 GCS E2 VT M2 gt 1 17 15 A B
15. 8Fr A 19 30 Eg 8Fr
16. 12Fr 120cm 70cm NG ED 33 77 EE ge
17. 10 35 7 5 40cm CT NG N
18. a ae 10 30 A 1 1 2 3
19. CO02 IPH 60cm 30 Spo2 1L 10L
20. 6 30 4 1 ts 4 6
21. 19 00
22. 1ICU to 68 77 30 10 30
23. 69 77 _ RT ER 38
24. 14 26 17 30 SpO2 D D CT 21 51 CT CT 23 00
25. 2 2009 9
26. NG ER 32 77 0
27. 3 23 24 2 2 CS 4
28. 18Fr 14Fr 14 400ml 16 20
29. 4 17 5cm
30. 10L 12 55 2
31. EOG 6 10 25 A
32. 1 2 46 77 1 6 20 00
33. NG 53 77 1 1 2 8 10 2 2 3 3
34. ie A WE 2 B
35. 6 0 1 na 77 77
36. 2 sBP50 80mmHg I 10 25 7 5Fr SpO2 10 35 2 10cm SpO2 IVH IVH
37. 1
38. 3ml h 3ml h Dr
39. SpO2 8096 2 40 77
40. X P X P 3 X P P
41. 3 1 3 gt
42. 2
43. 20cm 10cmH20 1 1cm 21cm 26cmH20 5 50 SP02 849 37 5 55 1 1 6 00
44. 77 gt WC 3 1 E 2 23 5 25 1
45. SpO2 9 O X PEEP 10cmH20 X
46. CT 5 6 4 22 15 5 24 00 6 8 30 42 7 7
47. 6 AM4 20 A 5g 333g 5g 50kg 800g
48. mh 110 60mmHg CT CT b CT 117 60mmHg 75 lt
49. 5 V F100 ml H i 21 77 a DIV
50. Ei CV CV CV ICV 1 1 19 77 39 CV 40
51. ES oO 1mm 4 6mm X
52. 30 MR A Es 8 ICU 1ICU
53. ACT 395 S Kids 420 S 10 1 22 0 5
54. 2 4 24 9 30 2 3 3 1 2 4 1 3 1
55. SpO2 659 PaO2 58 1 torr 8 CV CV 0
56. LE 2 3 4
57. 20cmH2O 20 40 20 air 20cmH2O
58. RS 23 28 70 BVM 10 o 7 5 SpO288 899 7 30 SpO2709 7 33
59. 8 0C S Servo i V3 0 PS CPAP 2 22 00 7 10 24mmHg 34mmHg 2 8 11 50
60. 6 6 6 7 70m h 7 8 30 Sp02 15 7 8 9 8
61. 1 2 1 1 lt 1 5 75 77
62. X 6 2 as CT
63. Sp02 2
64. SS 7 77 10 2 6 CT
65. lt 0 1 0 59 2 77 gt EnRhythm E 3
66. 5 CT 10 4cm 2 6 CT 10 Pi A JCS20 17 B2
67. 2mIl 20 30 2ml 50ml 8ml 50ml
68. 40cm 9 10 22 45 1 6 11 0 15 12 0 20 1 10 13 GCS E3V4M6 2 1
69. CV 2ml
70. 4 3 Sa ar A
71. X 100 X 28Fr CT
72. 9 1 2 2 3 1 4 5 5 6
73. MRI MRI MRI 66 77 840 8mm SPO2
74. 2 3 18 90 4 1 1 1
75. 12 Fr Aspiration kit laspiration kit 1000ml IARDS sat 30 drain
76. 490CS a i 1cm 2 6
77. 4 8 SPO2 4 0 1A 19mln 1 ml 3 5 1A 19min 1ml 1ml
78. a 6 E 5 85ml 1000ml 945ml 2x10 8 0 RU2
79. 2 2 FiO2 60 3 2 3 4 12
80. 8 3 4cm 11 30 ICU 100 99
81. 13 08 1AIV 4 Sp02 989 170 140 1 1 25 77 a 7 a 7 4 2
82. 14 77 oe 2 PCPS IPCPS PCPS ME
83. 2 a 2 JMS 1 17 15 2 18 00 2 SPO2
84. 21 48 7 22 03 Spo2 9796 HR 110 22 10 22 30 RE RRR 9 20 1 1
85. 15 77 1 EE a 1 15 15 20 15 15 20 2 16
86. CO2 2 1 20 1 0 45 SPO2 3 1 SPO2 15 lt 30
87. TV 600 300 SPO2 1009 989 20 45 3 A B SPO2 9096 20 50 50cmH2O
88. B 1 1 1 gt 2 3mm 2 2 3
89. MRI EE MRI MRI MRI 2 MRI
90. 5 FDL 6 ee 0 28 77 1 2 1 1 6 1 2
91. C A 20 77 3 CV x CV 12
92. S 22 35 ICU lt 0 2 10ml h 1 5 2 7 30
93. 5 BK 1 33 2 0 3 2 2
94. 1 NIPPV 1 NIPPV 20 55 NIPPV 2 HR40 NIPPV NIPPV DNR CT
95. 5cc 35 77 A OT CE 2 200ml h 2
96. 6 3 3 1247 3 GUI CPU PC 4 5 3 ME SST 6 ME 20 56 1
97. KUB CT 30 1
98. 3 SpO2 80 SpO2 28 HR30 25 48 77
99. 8 10cc 3 X
100. NG J VAC VAC 1 SD 4 10 cm cm
101. IEOB MEI 22G MRI CT gynamic
102. 10 lt 30 B 39 77
103. 7 8 12 30 11 20 12 30
104. 22mm 26mm LA 22mm 3
105. CT 2 8
106. 23 1 PN KTP 1 4 iid
107. CV 22 B CV TPN TPN 50cm 2
108. 12 ICU 17 ei PCPS 13 ICU 3 77
109. lt SPO2 SPO2 2 0 00 5 00 2 7 15 SPO2 02 10L JCS
110. 2 2 0 1 3 12 77 hai SS HIP System K MAX 3 3 4 4 WU TE rE RE Rt
111. 3 61 77 0 le ae 29 ICU 1
112. 5L 16 16 20 1 2 2 24cm 3 1ml h JCS2 20 SPO2 98 16 45 17
113. ICU 2 X Sp02 CV CV CV CV 5 SpO2
114. 8 2 10 40 3 12 13 14 05 1 10cm 18 60 77 gt
115. O a 10 77
116. 2 ke 13 77
117. 4 30 1 2 3
118. 7 35 1 2 SpO21009 3 9 Sp029096
119. risk 73 77 ga 840 Te 74 77
120. 2 3 0 6 7 10
121. ICVC CVC CVC 116 PI NG 4 117 4cm 1 18 30 1 1 1
122. SAT809 SAT969 CT ICU 49 77 2 HAMILTO 21 55 A 21 30 HCU 1 IHCU HCU 3 HCU
123. 0525 1 0525 1 ll IVR MRI 2 C 1
124. 14Fr RA 500ml JIS 13 00 20 15 30 10
125. a et WeM 54 Picc A 3 2
126. 7 45 1 7 55 1 40c
127. SP02 959 6 32 6 14 21cm Fi02 309 SP02 959 6 16 SP02 3 10 SP02 889 939 6 30 6 40
128. 2 3 80 3 13 00 4
129. B IME ID ID A ID ID B B ID A B
130. 2 7cm 2 30 CV 2 3 3 2 1 4 20 6 4
131. 8 29 77 1 I 3 2 ICU 2
132. 2 7 1 RC ai 10 14 2 RT A 10 25 10 30 PCPS 10 39
133. 3 ICU 24 1 0 3
134. BK 3 3 4 BK BK BK
135. ICU 02 CT 9 77 EN ECMO IECMO AC 16 10 ECMO ECMO 20 57 ECMO ON
136. 4 SPO2 9596 SPO2 1009 0 77 4 30 PE 1 8 5ID 9 0ID 4
137. 8 SPO2 98 999 B 2
138. C C C B A 2 6 38 4C B A IE TG MRSA
139. 3 2ml h 1ml h 18 4 JCS2 10 1ml 18 2 24cm 5 2 55 JCS2 10 6
140. eR ge gt ee RR ENBD N 3 IPICC P ICC 41 7
141. 4 CO2 SPO2 5 3 2 B SPO2 9496 9596 0 2 15 B SPO2 SPO2 94 SPO2 30 1
142. 10 3 0 1 1 45 11 45 14 40 4 6 77 a 1 1
143. 1 20 lt 40 ng ml 2 3
144. B Sat 889 8 Sat909 HR150 BP200 Sat889 6 BIPAF Sat1009 3
145. C 5cc C 19 30 21 C 21 30 B SpO270 NG
146. 10 3 ERI ERI ERI WM 3 2
147. 16 18 14F r 18 45 2 RE
148. BK 1 77 We 3 i 1 2 2 ME 22 00
149. EE DE lt CT 4000mL 2
150. 23 50cm2 CV 23 10 MRI C TPN TPN
151. 7 00 ICU 50mg 7 11 ABP137 58mmHg BP 122 58mmHg 87 SP02 89 93 ECG 7 20 SP02 939 SP02 93 1009 7 32 ICU A g 7 35 50mg 8 0mm 23cm SP02 1009 ICU oO 23 77
152. a me gt em NE 3 BE OR 22 00 NG 40ml 22 52 2cm HR131 SP02 83 GCU 5 59
153. A off B A 11 77 ZS 930p 7 5ml 1 1
154. V 3 5 25 0525 1 0525 1 CT 6 77 5
155. SPO2 969 i ee M T ED 83 M T 84 em i 85 31 77 a i
156. 2 5cm 2cm SR
157. TME61T 9 HR80 HR70 gt 3 ME 3 4 NIPPV ME 5 NIPPV 4
158. 3 3 4 4 6 2 4 5 5 5
159. 2 30 a 0 SP
160. 2 28 1 1
161. 63 77 4 0 4ml H 70ml H MM 64 77
162. 7 7 HR30 3 1 1 4 SpO2 5096 HR110 B P110
163. OE CE lt 17 17 50 Hb
164. 1 3 250 PR 60 Biotronik EDP30S
165. 8 3 HPLC PT 20 40 5 3
166. A 22 77 1 30
167. 32Fr MAP FFP CHDF CHDF 13 A 71 77
168. 0 15 C TPN TPN 813g 0 30 BP 84 52mmHg SpO2 989 BS 186mg dl 0 35 500ml2P 2L 0 50 RCC400 1P 2P PICC
169. 24 2 14 a 1 25 26 23 1 2 3 2 1 6 241 30 i MRI 23 1 1
170. 11 9 55 120 SPO2 95 9796 12 9 57 13 10 10 SPO2 95 9796 72 98 55 14 13 30 15 14 00 7 77 1 10 00 2 10 15 CT R68 la 2 S lb
171. 19 30 10J cm PH B 19 00 100ml
172. 22cm 20cm 23cm SPO2 849 6 TV300 C 21 00 C 3 BVM SPO2 10096 SPO2 1009 TV 500 800 47 7 a 12 30
173. 1 5cm ON 2 2 x 8mm 2 x 40mm ON Me A eR
174. MRI MRSA VCM 14 72 77 B A
175. 234 77 1 gt a 13 00 20 5 6 45
176. ED 4 77 J M i M T ie NG 2 3 30
177. U PCPS 1 G 19 1 PTCD G
178. 3 4cm M 76 77 EE JMS 2 5 000
179. 21cm 26cmH20 1 5 00 5 48
180. D 4 RVS
181. G NO SS 2 NG 1 157 2 77 1 1 163 ae 6
182. 17 30 NG 4ml CT CT VS 55 77 175 76 1
183. 1ml 2 24cm 1 2 55 ae EE GE 6cm
184. 5 SPD
185. 5 SPO2 6 7 16 77 UV7001K Narrow Band UVB 0 3J 2 UVB 0 3J
186. 7 ICU Ma NE
187. 4 3L 1 lt 1 30 ICU 1 30
188. 4 EN i 241 100 2 3 1 4 5 MRI 6 7 8 YAG 9 10 11 2 3
189. 13 A B A B A A SS A A B A A B A A 100 B A 4 5 B B A A 20cm 2 2cm
190. 4 1 cH6048 2 3 2 cH 6048 B cH 6079 B B A cH6048 A cH 6079 A B B A 1 30 B A
191. 43 77 JMS A R
192. 7 8 9 6 77 JE 3 ADL 6 40 7 30
193. 6 C02 7 1
194. 1 OFF ON OFF 21 10 AC 21 25 ECMO AC 1
195. 2 2 1 29 18 4 1 3 5 50m 10 170ml 24 2 GCS E4V4M6
196. MS 3 10 3040 300 Hb3 3 K 4 5mol 8 CT p
197. NG 1 i NSR 2 3 4 2
198. 84 5 min ah 02 8 L 12 L Bed CT lt ICU LCU ICU CT CT
199. 25 2 70 77 J VAC JJ VAC
200. B A M 5 B A
201. SPO2 SPO2 7 9 46 15L SPO2 8 9 50 EKG 9 9 52 SPO2 869 150 10 9 53
202. 2 PBSC 3 9 30 5 5 5 2 1 2 17 77 8 O CV 26
203. 2 3 Dr 4 SPO2 504 Dr SPO2 SPO2 7 air 5 19 57Dr 6 8cm 9 5cm 7 SPO2 100
204. PO2 Y 10 25 SPO2 FIO2 0 3 c 1 0 DNAR HURHIN 10 30 11 45 DNAR d e 14 40 SPO2
205. 7 A N 37 77 29 GCS E4V4 5M6 i gt
206. E
207. PMDA No 25 MRI 1 RI a 02 8 S 4 T 1 30
208. 2 5 o 38 77 10 3 1 X 2 4 0 X
209. 3 CT 8
210. HCU HCU L Spo2 749 HR 140 100 HCU 3 21 57 Spo2 85 879 6 30 35
211. SP O2 30 67 77 i EE Sp02 oO 3 19 30 NIPPV 2
212. 15 40 B A B A 14 B B A B A 14
213. 3 A 18 4 4 NST 1 PG 5 NST 4 18 50 B 5 18 6 7 8 SPO2 9 30 77
214. 20 FDL 2 BP 90 Hb 6 9 8 4 2 BP 50 DOA DOB 2ml h DOA 10m h DOB 12ml h SPO2 939 VTM FiO2 0 49 0 596 SPO2 96 9796 BP 70 80 Hb 8 3 FDL 9 77 9 ee ee
215. 300ml DIC 44 77 ia ADL
216. CT a hrw CV CV lt a TV
217. a ee SM NG NG 14
218. 10 6 45 500ml 3
219. 22 54 HR94 SP02 50 22 55 HR128 SP02 85 23 00 23 10 X P i rtd ye ida rl 0 RR 2 2 3 3 19 30 SPO2
220. 2O 2 2 3 2 3 3 4 2 0 20 4 10 3
221. JMS M M dass JMS M 1 77 M 5
222. TV O2 SPO2 629 TV 3 O2 3 1 8 45 1 1 2 8 55
223. 4 15 5 4 20 HR 130 160 55 33 9 Hb10 5g dl 8 0g dl 6 4ml 45 77
224. PH CO2 2 gt 8 14 16 1 Ocm i
225. 1 1 24CmH2 80 30 O 2 2 2 2 A B 80 3 80 10 3 NST
226. 19 ME 22 0 620ml 400ml 250g 3 5 1 20 40 1 1 1 1 22
227. 2 2 G 3 2
228. F 3 0 NN i CT 13 CV CV
229. 1 58 77 SB 2 4 SB 1 8 SB 1 CT CT 1 FDL
230. 3 SD 3 18 7 4 21 5 22 6 7 22 25 8
231. A 28mmHg 50mmHg 34mmHg 12 00 A B B B SP02
232. 4 PTCD 36 77 B 23 30 NG 0
233. 6 CV CV 18 77 Me
234. 2 25 23 6 23 26 23 9 28 1 P 1 2 P 7 mms P 66 3 P 67 23 3 1 E
235. 2 SpO2 309 6 2 3 SPO2 3 4 50 5 00 2 2
236. 2 00 lt m pat 5 2 500ml
237. 2 5Fr 2 3 3 5Fr 4 5 6 HR SpO2
238. 27 77
239. FiO2 0 21 SPO2 24 77 i a 17 50 19
240. 2cm x 5cm 65 77 MRI MRI
241. 2 SPO2 3 9 15 9 20 2 SPO2 SPO2 94 959 6 3 3 4 9 25 9 30 SPO2 94 8996 10 SPO2 979 5 9 36 6 9 45
242. 8 496 4ml 4ml 80 40mmHg 130 150 HR 30 BP 20 mmHg 4 5 4 CT 2 1 1 2 ICU 1 26 77 ey
243. A 6 Sp02 90 lt 959 7 45 Sp02 759 SpO02 4096 CO2detector 1009 SpO2 HR 1 1 1
244. 3 Na 3 05 A SPO2 95 EE 3 50 FL 152 0 19 2 20 1 8V
245. 4 gt A 4 B 2 18 204 108mmHg 63 JCS30 16 18 200ml
246. 1 1 2 3
247. 2 SPO2 OE ICU ICU 8 1 2 PCPS IC
248. 80 60 B B SP02 60 509 6 HR64 SP02 30 1096 12 10 C 12 25 SP02 80 PS SIMV 40 50 SP02 909 12 50
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