医療事故情報収集等事業第20回報告書の公表について
Contents
1. 1 2 1 1 0 1 2 1 1 1 6 2 4 2 1 5 3 32. 161 6 1 6 1 1 6 2 0 10 1 2 1 1 9 1 9 p 1 9 3 1 9 4 2 1 10 1 2 1
3. 156 3 4 2 W038 1 No 3 3 2 1 8 6 1 8 1 2 1 6 1 6 1 1 7 3 2 0 2 2 1 6 2 1 10 1 2 1
4. 11 1 11 12 13 13 13 14 3 0 15 15 16 151 II 2
5. 2 0 1 2 http jcahc or jp htmlaccident htm 1
6. 1 No 9 20 152 154 2 j Ne 23 20 155 156 3 No 33 20 157 159 4 l10 20 160 161 5 16 20 162 163 20 http www med safe jp 2 3
7. 1 0 0mg 5 0mL 0 2 158 3 6 2 1 8 0 2 1 0 0mg 5 0mL
8. 2 163
9. 3 1 D 4 PH S
10. 1 5 1 38 ir 4 5 1 OOGt5 3 3 7 OO 15mg 1 1 3 7
11. http www mhlw gojp shing 2010 01 s0129 4 html e e 8 03 5253 1111 9 30 18 15 154 3 3 No 23 1 No 2 3 2 0 1 0 3 1 8 1 2 0 8 1 9 2 2 0 1 2 1 3 2 1 1 0 1 2 2 3 4 3 4
12. 1 8 1 2 0 2 1 2 2 1 1 0 1 2 1 3 8 3 8 2 1 A B 1 4 0 1 6 0 1 1 A 1A 5 0mL A 1 0 4 5 0 8 0 1 5 0 3 4
13. 2 2 1 2010 online lt http www mhlw go jp shingi 2010 01 dI s0129 4a pdf gt last accessed 2010 03 08 153 21 5 5
14. 2 2 6 9 3 2 3 1 150 3 3 1 2 1 10 1 2
15. 2 C T CT P S C 2 MR 1 CT CT PH S C T C T 160 3 3 P 0 SITIVE NEGATIVE
16. N 9 1 No 9 4 1 8 4 2 1 1 1 9 8 1 6 1 0 1 9 3 2 1 1 2 1 1 0 1 2 3 2 3 2 9 To 12 0 1 6 0 0 1 7 0 0 0 1 8 0 4 4 1 9 0 0 0 2 0 0 0 0 2 1 0 1 1 3 3 Ne9 No 9 2007 8 No 9 2007 6 lt
17. 4 1 9 8 1 2 1 5 5 1
18. SO 2 Ne6 19 5 4 we 7 19 6 Nu 8 19 7 Na 9 19 8 Na 11 19 10 Ne 15 20 2 NN 20 20 7 No 23 20 10 Nu 29 21 4 Ne 30 21 5 Na 33 21 8 5 1 0
19. 4096 S195 ng 1 5 2 RROD SG AOR RRA Uh ht 9 RUN HEI DTE CCB BETOR RD 00me MIE 1 T2109 HECR MO TERRLCT 10 15DOmg mead i True Ome el 51 015OOmg WOK eos REE BMELCR TDR KF RT AE MRILSLOTT EO FREDTTT TTYTT 7 bit yeade ocie bo ionk Mn SO O MRA MEWCNSEE RTO TAH MLTR ORBEA EOS RORORR ENRLAL NIREERNTREEAUR OE Pa 3 io o6 EE 1 EE EBERT 8 0a Pr O3217 059 Ra ttp ripmtniMndacrtn 152 3 2
20. fe DK Ve ggLt YR 9 Neve kee mistaUaecen Mint edie 5ohMeoD amp cA DMCAEWE VTL MO Bt AB CETYYYY AE 93 203 F101 0081 TeTHNPE MD 417 10 ein 02 69170252 mm PAX ROOT 155 HI 2 1 1 5 mg 4 5 3 0 1 5mL 4 8 7 5mg
21. 7 1 1 0 0mg 2009 6 2 5 0 0 mg 2 0 0 9 6 159 5 1 0 1 1 0 1 9 4 6 1 1 9 1 2 1 2 2 1 1 0 1 2 1 2 3 1 6 mL h
22. 3 6 3 6 No 39 2009 8 PT oo No 33 2009 8 1 6 2006 1 1 PO09 5 390 3 R 100mg 100 5D0 10mg 100mg SM 5DQ
23. 1 9 2 2 2 3 2 6 2 0 22 8 25 0325 2 0325 2 0 3 25 2 0 3 2 5 2 2 2 3 25 ry E 2 0 1 6 1 0
24. 4 No 9 2007 8 4 2O04 10 1 2007 3 81 B i H 409 51 18BDmg 9 pg Ei O 1 125OmE BORES1 8Bmgt125D D 4 lsoonet 390x0 52 ERE 7 1 Min Rt 2BOmk 1095 810 1 R 1 25g 2 Pie4 1 8 2 CanongiC 9 NE 40Omwe 4 ig5Omg 1250mg 9
25. 1 3 4 6 7 9 1 10 12 8 RG PD 1 6 0 0 17 0 0 0 0 0 1 8 0 0 0 0 0 1 9 0 0 0 2 2 2 0 1 0 0 0 1 2 1 0 0 1 2 3 3 5 Ne 23 No23 2008 10 ses 2 4 9 i Smg 5mg No23 2008 0 PI Tot RM EOC ER No 23 2008 5 tis oT Ding 3 6 5 2OD6 1 1 2OOB B 91 13 E 5 5 55mg ST
26. 1 2 5mg 1 2 5mg 2 5mg 1 0 1 2 5mg mg A 1 2 5mg 1 2 5 mg 2 3
27. 10 1D0mg B00 BODmg 1 1 1DDmg or 0 5DOmg pre ee TT 3 7 Nu 33 8 EE EDT TT gt 2X Bcni 2 PE EE IN 1800mgt 50mL 0 A D 5 0 2 100mg 50mL O FPN Br CAPA OE OT TT RT TT TT ee SENDREA RG RIA ER RI EEALCIDN ET ED RN RDIRE H
28. 1 5 0 1 A 5 0mL A B A B A B 1 162 3 3 5 1 2 1 1 4 1 9
29. 2 R 2 4 24mL 1mL100 3 4 2 0 1 0
30. D 1 C 1 6 00mg 5 50 0mL 0 3 2 2 0mL h 4 4 in 5 gt
31. 314 62 201 3 199 2 1 20 73 82 2 20 83 118 3 20 119 126 4 20 127 134 5 B FIB 20 135 139 6 20 140 149 3 20 150 163
32. 1mL h 6mL h 2 A B 6 mL b B A 6mL h 1 mL h 1 0 B A 6 mL h A 1 mL h 6 mL h B 6 1 A B A
33. 2 0 1 1 21 10 12 1 2 21 a a 21 10 12 0 11 2 2 Wa 119 164 159 442 8 1 8 30 6 8 138 1 2 0 5 WW 15 10 15 40 113 25 6 39 8 8 28 3 3 9 2 0 30 6 8 i 0 0 0 11 2 5 427 427 427 8 190 43 0 20 21 24 49 11 1 442 100 0 20 31 2 21 7 9 1 232 978 2 20 55 62 945
34. T SONG ERRNO RA EMR REITERMTREERLRDT NU A 7 ID PNG FAX OS E2170283 MA 157 II 2 F 2 1 1 2 1 00mg 100mg 5 0 0mg 1 0 0 5 00 1 0 0 500 1 0 0mg 50 0 1 0 0mg 5 0 0mg 1 0 0mg 5 0 0mg 3 1 DI C 1 000 mg 5 5 0 0mL 0 2 2 0mL h 3 3 1 9
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