医療事故情報収集等事業 第30回報告書について
Contents
1.2.
3.
4. 3
5. 4 Web 2 2 7
6. 1 17 1 8 1 9 2 0 2 1 2 2 2 5 1 114 1 296 1 266 1 440 1 895 2 182
7. 7
8. 134 2
9. No 6 8 2 BA
10. 115 pak 9 D 7 1 MR I 2 0 0 9 2 JIS JIS Z 4951 2004
11. 1 2 3 7 2 4 6
12. 2
13. 2 4 4 6 3 0 MR
14. 3 2 2 5 2 1 3 2 3 3 1 6 1 4 6
15. X 2 6 A X TV B
16. 3 lt
17. 6 140 2
18. 1 2 2 BH 2 5 2 6
19. N N 2 167 4 5
20. 1 55 DERN Z EREI O 153 SM 2
21. ABAT I MR I 10 Gies
22. 1 http www mhlw gojp topics bukyoku isei ianzen 2 http www med safejjp
23. MR MR I Jes ME 1
24. 1 6 1 0 2 2 2 1 MMI RESY AY
25. ZU G _ 2 7 2 3 9 3 0 2 8 2 3 1 2
26. DIC 1500mg day 0 69 4 184 No 67 2012 6
27. 2 EEP 10 EEP 20 RER WVL 6
28. 9 1 2010 09 22 9 2 MM I 2010 05 20 7 3 MM I 2012 5 29 Online available from lt http www muranaka co jp item material newpage2 html gt last accessed 2012 8 8 4 MM I RESY 224 lt lt 7 Online available from http www muranaka co jp item material 50201400 006 html Last accessed 2012 8 8 5 5 2010 2 157 2 4 SMC
29. 3 3 16
30. 10 29 MR I MR I M R I
31. 7 5 2 IDC 1 MR 1
32. 1 tir LT 2 2 2 6 1 6 9 2 1 1 6 1 3 3 http wwwmed safe jp 2
33. 1 2 1 2 2 3 1 3 O
34. ICD MR 5 I CD A C T MR 1 MR I
35. 2 139 D wa wa Sa ks Sisi a wes sap Sq SR B Piran et wa PS PSS lt 1 gt
36. 2 5 1 2 1 1 1 1 1 5 1 4 1 5 165 x 1 0 m n 1 n 5 n 1 2 No 3 3 1 No 2 1 8
37. b 1 3 4 6 7 9 10 1 2 http www med safe jp 27 I
38. 3 CT ni ot SI 171 T TE w qS On gt CT gt
39. 1 2 6 7
40. 3 9 3 3 2 0 9 1 6 7 11 1 3 2002 841 847 2 2010 2010 2 1 3 2 206 2 4 1
41. 7 546 X 1 0 0 3 010 2 36 3 85 4 96 3 0 1 0 gt
42. 3 2 2 3 0 1 2 2 1 2
43. MR I Cb 24 R 5 s MR I
44. h gt 4 2 4 4 1 6 3 0 4 85 2 1 MR 1 MR I Magnetic Resonance Imaging
45. 3 No 67 2012 6 0 lt gt g 2000 2010 1 AE ua 70mg G5mL 1 20
46. P TP 5 PTP 2 i
47. 5W1H rn When Where Who What Why How
48. 3 1 164 3 3 1 2 4 4 6 MR 1 No 2 No 1 1 4 1 9 3 7 1 9 6 9 1 9 8 1 9 9 0 9 2 0 6 gt No20 2 0 7 NO 2
49. 84 1 3 1 1 2
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51. 2 1 QA 01 B 45 1 144 0 8 0 13 0 0 4 0 0 1 14 0 63 9 1 1 14 0 54 0 16 0 1 0 17 u 9 0 38 0 2 0 1 0 1 0 9 0 0 51 11 0 262 1 39 0 12
52. 5 WRAAE 7 149 WOE S 10 3 3
53. 154 2 1
54. 92 2 No MR 1 MR I Dr MR I
55. I CU 2
56. 160 2 6 1 1 2 2 2 2 2 1 5 2 3
57. MR I MR I MR I 114 2 O
58. No 4 8 7 6 4 8 3 4 6 2 2 2 3 22 23 No 48 98 981 4 6 91 459 No 51 88 524 55 2006 2009 87 629 45 2 82 280 50 2
59. MR I O MR I O I O
60. 4 D 2 LUTO Hab RADD o 100 2 O MR I O MR IRA
61. 2 3 MR I MR I
62. 2 2 8 2 28 PEM Ca TEDE OM 4 1
63. 6 MR I 98 2 ii
64. CT 3 4 2 2
65. 95 pak 20 MR MR M R 1 M R 1
66. 173 T TE w qS On s174 1 8 1 2 2 4 4 6 No 6 No 6 7 1 2
67. 0 0 0 0 0 0 0 0 0 1 0 0 1 5 1 0 0 0 0 0 0 2 0 0 0 8 2 4 8 0 1 0 3 0 4 2 0 1 25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 4 F 4 14 4 of 5 2 5 2 ol el 3 45 4 0 0 0 2 0 0 1 4 0 0 1 12 0 2 1 0 1 1 0 0 0 0 0 0 5 3 7 3 1 1 1 12 1 0 0 0 3 32 1 0 0 0 1 0 0 0 0 5 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 19 29 17 2 11 5 20 4 10 14 0 8 139 19 48 16 34 14 0 61 139 2 2 6
68. DPC 144 2 5 O 3 3 1 3 O 3 20
69. MR I MR I MR I MR 1 MR I
70. MR I 3 2 9 MR 1
71. M R I 101 MR 1 2 4 1 4070 o gA 204007 I CD
72. 2 7 2 8 2 9 2 7 3 0 7 1 2 2 3 4 1 5 Online available from lt http www nichiyaku orJjp action Wp content uploads 2011 05 high_risk_guideline_2nd pdf gt last accessed 2012 07 18 141 3
73. 1 9
74. 2 2 2 26 gt 5 7
75. 14 A 1 1 RANS TOR REAREN B C 14 G A 1000mg
76. 21 22 2 1 1 3 1 0
77. Ca 4 2 1 3 3
78. O MR I O MR TI 5 MR No 1 0 MR I No 5 6 MR I No 6 2 6 MR I
79. HSE ck 0 0 0 1 1 1 0 1 0 2 1 0 0 0 0 2 0 0 1 0 0 1 1 1 1 1 1 6 2 18 No 30 1 BCS MAE BS157mg dL 7 7 30 1
80. 145 2 3 2474 O 1 2
81. 4 2 9 2 3 7 1 129 2 2 LIHIIr D 2 4 3 3 1 1 2 9 9 2 4 4 1 6 30 5 7 3 1 8 7 2 1
82. 1 3 Rp 20mg 1 20 m g 6
83. PTP 4 HPM 0 C T C T HNW 1 6 cm PTP 4 5 N C 1 2 1 5 meg 1 1 1
84. P ET P ET 10 10 00 5 89mg dL 10 45 48mg dL 50 15mL PET PET
85. 1 6 5 4 6 6 5 P TP 4 No 3 3 1 6 6 169 No 47 1 7 0 1 7 4
86. O O O O O MR I MR I T C C MR I 110 2 O MR I O MR 1 MR I
87. MR 1 O O
88. MR I 96 2 MR I 1 2 9
89. 4 EC A 1 B A A
90. 2 3 1 1 2 1 2 2 _ 1 2 E 2 4 1 3 2 4 5
91. 2 6 4 2 0 5 2012 5 25 6 7 1 286 6 7 We b 49 1 135 51 1 129 48 9 264 100 0 1 1 1 1 2 9 9
92. 1 Y No 67 2012 6 e e SS 2 06 2010 1 19 3mL
93. MR I MR I I D MR I X M M R I R M R 1 x M R MR I
94. 1 HB 2 1 5 0 4 8 mL 3 2 2G 1 2
95. 130 2 2 21 1 656 HB 84 ooo 3 1 24 38 34 2 2 2 2 22 ARE 1 733 1 3 9 5
96. MR 1 CT M R I I E C International Electrotechnical Commission JIS 24951 IE C 2 0 0 4 JIS Z4951 2 1 M R I
97. lt 2 gt
98. 2 MR I MR I ii MR I C D
99. gt 5 1 2
100. 2 432 2 2 24 JERE P I 24 C R 20 12 9 71 K Y 3 2 1
101. ET 106 2 2 6 EL 3 4 6 1 2 13 2 7 2 0 2 9
102. I CD TI CD i MR I MR 1 ID MR I X MR MR I
103. 3 2 3 1 No 6 3 5 3 0 0 3 175 4 No 6 5 No 65 2012 4 nm 6 9 9 No 65 2012 4 Z 9 2008 1 1 012 29 22
104. O MR I O O M R ii MR I O O
105. 2 0 7 7 1 2010 International Patient Safety Reporting System Conference 2011 The International Society for Quality in Health Care SQua 2 8 2011 China ASEAN Forum on Reform and Administration of Public Hospitals ASEAN 2
106. 7 4 L EU SE 3 0 1 2 4 4 6
107. ARI 2 30 NZ AN z yy pa 2 RA _ 152 2 4 1 FATRE
108. A X A B Y B B A X A Y A B d A 1 No 67 2012 6 e 2010 1 nr
109. 1 45 151 3 279 5 442 8 917 2 4 5 33 66 108 3 3 48 345 799 1 195 4 1 20 337 500 858 5 2 25 863 3 487 4 377 6 4 22 744 1 213 1 983 7 8 65 2 344 4 721 7 138 8 11 42 1 688 1 764 3 505 78 378 9 633 17 992 28 081 11 38 14 76 230 358 21 43 109 1 035 1 703 2 890 3 1 14 166 247 428 41 53 3 109 700 865 73 31 984 61 3 9 07 5 0 0 5 9 9
110. MR I M R I
111. 8 THE UNIVERSITY OF Toryo King s College Hospital LS Foundation Cecscseacscacecscecececacececscacecscecq w SHARING FINDINGS FROM EXISTING RESEARCH WORK ON PATIENT SAFETY 5 juse 2012 The University of Tokyo Hospital UTH UK debegates 17 6 2 2 Canadian Patient Safety Institute cpsi icsp Global Patient Safety Alerts 1 7 3 2 2 2 2 Project to Collect Medical Near Miss Adverse Event Information 2010 Annual Report
112. N o 3 127 C LIHIIr 2 19 A BRI No 1 1 2 7 No 3 No 2 PE T
113. MR lt gt 1 6 MR I 2 MR I 3 0 4ms 2 0 V MR I 1 0ms 5 0 V MR I gt 1 MR I MR I 2 MR I MR I 3 2 0 0 0 1 5 0 0 0 M
114. 1 2 2 15 1 HU 2 ii 9 PTP PTP 2 3 PTP 1 0 0
115. 1 2
116. 4 3 1 2 1 2 2
117. 100 mL 1 1000 10mL TF No0 1 100 mL 100 mL 1000 10mL OOOOC 8 3 1 178 No 66 2012 5 2 A 1 R HR 100 mL 10mL 40 40mL
118. 2 143 AC txi 8 2 0 1 0
119. MR 1 2 MR I
120. 2 1 1 3 5 6 5 4 2 1 1
121. 5 1 0 T 3 x 4cm 5 8 5cm 2
122. MR I I CD Implantable Cardioverter Defibrillator MR I
123. 1 2 5 X P CT CT X P 1 2 5 3
124. O ii No 3 O PTP P TP P TP 1 6
125. 10 3X4cm 5X8 5 cm 1 182 No 67 2012 6 cC G 9 e e S lt gt g 2000 2010 1
126. O MR I ee di 0 0 O I O MR 1 O M R I MR 1
127. M R I MR I M R I ECG 11 MR I 2 MR 1 1
128. 109 MR I C pak 20 i 7 I MR I MR I Q MR MR 1 MR
129. 1 36 105 1 673 5 215 7 029 2 6 7 45 63 121 3 5 45 212 868 1 130 4 3 15 153 478 649 5 ND 6 39 717 2 905 3 667 6 8 19 520 1 248 1 795 7 9 54 1 318 3 706 5 087 8 12 45 764 1 129 1 950 85 329 5 402 15 612 21 428 5 1 13 30 133 540 716 2 24 32 520 2 095 2 671 3 2 7 90 239 338 4 1 5 37 268 311 47 25 357 3 10 08 6 0 0 1 97 559 7 386 20933 28 975 2 22 20 178 345 565 3 35 213 808 3 014 4 070 4
130. 2 vya tos A a sassa ay 3 600 0 5 SSP 3Sosi 0 34395 45 0 44 A IAMUE MIE 24 LI 8 45ait0 EPI 2 TU L UL EHA N 3 2 LERING L 1 2012 qr 5 M 29 lt it 2012 F5 H 29 4 3 K61 925 005 03 4 BRAY 27 7627 717 MRE D 2 06060 SERR
131. 6 2006 1 1 8009 6 30 3 ao 5 0 2 100mg 50mL 100mg 100 500 100mg 100mg 500mg 500 100 10O0mg 500 500mg 100mg pana 500mg 024 217025 2 Wa FAX 095 hc riphtmendex hn
132. E 2 18 QA 42 A 2012 1 6 2012 4 6 2012 1 6 IE A jh 0 0 0 2 0 2 0 0 0 0 0 0 10 1 9 16 1 5 0 0 0 4 0 4 4 0 8 12 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 518 97 4 1 068 96 9 532 100 0 1 102 100 0 44 2 X QA 64 A 2 19 T OIN AO I IO I IN IO OI O IO O O O OI rO IO O Q IO O O o 1 i 1 1 1 1 1 1
133. 1 6 1 No 5 0 2 6 9 6 2 5 0 6 6 0 4
134. 2012 2012 4 6 1 6 0 129 93 1 41 33 2 34 23 3 21 22 4 9 19 5 13 14 6 5 8 7 5 9 8 4 10 9 1 7 10 4 9 11 20 5 21 21 30 2 2 31 40 0 1 41 50 0 1 51 100 0 1 101 150 0 0 151 200 0 0 200 0 0 273 273 35 2 4 4 1 6 3 0 2 9 2 1 0 2 9 QA 09 gt w 2012 2012 1 6 2012 1 6 6 30 4 6 4 6 RH 5 1 1 4 4 92 10 15 44 74 140 7 10 15 33 350 16 21 31 60 34 0 0 0 0 621 34 47 94 171 2 10 QA 10 2004
135. B 130mL h 2 3
136. 159 4 3 1 5
137. x 3 4 162 2 5 5 1 6 2 3 1
138. u aaa 45 E X EY z z 2012 2012 2012 2012 2012 2012 2012 2012 gesal 2012 1 6 2012 1 6 2012 1 6 2012 1 6 2012 1 6 2012 4 6 gat 4A 6A 46A 46 4876 Rat 32 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0 2 2 6 0 6 2 6 0 0 6 21 74 7 0O o ol ol oO ol C 0O __ 2 11 u 14 21 6 20 1 2 30 62 4 ol ol of of of of ol ol 0 3 5 2 5 iol aj 6 el jo 3 35 0 22 3 __ 1 1 _ 1 _ 12 19 9 61 13 5 e 2 6 97 206 4 61 6 0 12 5 9 9 23 34 76 39 73 16 44 3 8 106 233 9 19 3 22 25 44
139. P V C peripheral venous catheter C VC central venous catheter 1 0 Omg 50mL 1 5 0 4 8mL 3 1 1 5 0 0mg 0 2 7 5 0mL
140. 2 CT 5 CT CT gt gt 3 17 5 18 6 1 2 4 4 6 No 6 5 6 7
141. 1 1 135 51 1 49 129 48 9 264 100 0 2 1 0 107 79 3 AZ 28 20 7 79 135 100 0 1 3 1 42 150 3
142. 1 http www med safeJjp 28 3 3 S SL W e b 4 3 1 2 92
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150. No 3 3 1 6 6 1 6 9 2 1 8 No 3 3 2 0 2 5 2 0 157 159 2 5 151 158 2 5 1 4 5 0 0 mg
151. 1 275 se nm E G 3 335 696 5 306 2 4 2
152. 6 6 2 4 4 1 6 3 0 1 2 1 4 3 0
153. EER 40 2 140 124 103 1 55 35 34 27 27 15 688 ST OT PT 41 2 14 QA 35 A 2012 4 6 2012 1 6 r 31 5 8 66 6 0 0 0 0 0 0 0 152 28 6 281 25 5 13 2 4 32 2 9 Za 37 7 0 74 6 7 20 3 8 48 4 4 222 41 7 468 42 5 57 10 7 133 12 1 532 100 0 1 102 100 0 2 15 QA 37 A 2012 4 6 2012 1 6 40 7 5 79 7 2 53 10 0 141 12 8 170 32 0 338 30 7
154. 1 3 1 Je 7 2 3 2 2 2 5mg 2 0 x 2 0cm 2
155. 91 pak 20 MR I 4 MR I 6 4
156. O MR I e ND ee MR I 112 2 O MR TI 2 1 O MR TI MR I D MR I M R 3 MR 2 0 2 4 4 1 6 3 0
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160. A O B A A 1 181 No 67 2012 6 e e 2 06 2010 1 gs 25mL h 20mLh A
161. B 1000mg 1 3 1 B 9 1 1000mg B C 1000mg 1 1 mL 4mL
162. N CD CD A N O O CO O O 2 MR I XM 2 2 1 6 1 0 2 4 6 3 0 MR I 1 1 1 3 j TucCOUyYCE 16 2 3
163. P TP 1 P T PTP PT P PTP P T 1 PTP PTP 9 6 1 2 5 P TP PT P
164. MR I 97 pak 20 MR I 4 MR I MR IAR C T CT MR
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171. gt 172 3 4 CT 5 2 2 1 0 No 4 7
172. 166 3 2 2 4 6 100mg 100mg 5 0 0mg 1 0 0m g 1 0 0 500 1 0 0 500 100mg 1 00mg 500mg 1
173. 90 2 MR I 1 MR I 8 MR I MR I MR I MR I
174. MR I O MR I MR I MR I No 1 1 O MR I O No 12 ICD
175. 8889 1 126 2 No
176. 2 0 3 0 X P 3 MR I MR I 9 9mg IV 6 6mg 1 2 IV
177. 2 2 3 4 20 8
178. MR 1 MR 1 MR I MR I MR I MR I E 7
179. D 2 148 2 3 4 3
180. gt G 100mg 50mL 0 2 No 4 7 17 0 17 4 2 2 1 0 No 4 7 2 3 4 5 3 6 37 No 4 7 1
181. C 2
182. MR I MR 1 MR 1 2 MR I 1
183. MR I 2 MR I 3 MR MR I 108 2
184. 2 16 PTP PTP 1 PTP _ 15 PTP 1 gt P TP P TP 1 1 PTP L A 1 P
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187. 5 0 0 mg gt T 100mg 50mL 0 2 3 6 2 1 8
188. MR I No 7 2 9 O MR I MR I O MR I O KDT MR I
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195. T P A 7 P M MR 1 MR I 8 C T 94 2 1
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197. 2 2 1 3 2 1 4 1 1 1 121 C LIHIIr D 2 1 5
198. 1 6 RE 5 6 161
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227. System Sea Risk Alerts Japan Australia Canada Denmark Counc for Guay Heeli Cara Medical Safely Infomation Hong Kong England and Wales European Union United States United States of America California Hospital Patient Safety Newsletters and Alerts Organization The Joint Commission Sentinel Event Alert Newsletter 10 No 4 8 5 9 Failure to check oxygen remaining Failure to implement measures to preventmather ta child transmission of Hepatitis B Wrong site surgery ight left nd Follow up Report jmsufficient knowledge ofthe administration status for warfarinpotassium and blood coagulability Medical SafetyInformation releasedin 2010 Specimen mix up atpathological diagnosis Accidental removal of the endotracheal tracheostomy tube when changing positions Medical Safety Information released from 2006 to 2009 Burns caused a high frequencyelectric current loop duringMRI examination Accidental ingestion of PTP sheets Rupture of the subcutaneousport and catheter m m m m m m m m m m m m Burns Due to Incorrect Handling ofan Electrosurgical Pencil 19 7
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229. No 4 7 1 No 4 7 2 2 1 0 1 1 19 1 2 2 7 H 2 4 4 6 3 0 H 1 RRI 3 4 1 3 4 6 7 9 1 0 1 2 1 6 0 0 1 7 0 0 0 0 0 18 0 0 0 0 0 19 0 0 0 0 0 2 0 1 0 1 2 4 2 1 3 0 0 0 3 2 2 1 2 2 2 7 2 3 0 3 4 0 7 2 4 3 1 4 3 5 No 4 7 No 47 2010 10 5 9 4 No 47 2010 10 1 1
230. 2 36 3 86 4 96 3 3 2 0 0 2 3 146 2 2 0 1 2 2012 6 18 732 1
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234. MR 1 MR I M R I 2 2 87 pak 20 D 2 2 MR I 37 13
235. 163 12 05 A N A PH 0049 2 3 1 2 4 4 6 1 7 2 4 PTP 4
236. 7 MR I ks MR IT M R 1 2 ElL MR MR I MR I MR I MR I
237. P TP 2 7 Ej 5 E 2 16 6 1 8 1 PT P 423 SEHA C D i 1 O 2
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345. 60601 2 33 2002 JIRA JSA 2009 200 4 3 American College of radiology MR Online available from lt http www ARC org mr_safety gt last accessed 2012 07 19 4 Guidance Document for safe MR Practices 2007 Online available from lt http Www ARC org SecondaryMainMenuCategories quality_safety MRSafety safe_mr07 aspx gt last accessed 2012 07 19 5 The Joint Commission Sentinel Event Alert Issue 38 Preventing accidents and injuries in the MRI suite Online available from lt http www jointcommission org sentinel_event_alert_issue _38_preventing_accidents_and_injuries_in_the_MRI_suite gt last accessed 2012 07 19 PMD No 26 2011 9 MR 1 Online available from lt http www info pmda go jp anzen_pmda file iryo_anzen25 pdf gt last accessed 2012 07 19 7 PMDA No 26 201 1 9 MR I 2 Online available from lt http www info pmda go jp anzen_pmda file iryo_anzen26 pdf gt last accessed 2012 07 19 8 Nazarian S Hansford Roguin Goldsher D Zviman Lardo Caffo BS Frick KD Kraut K
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364. ___ 0 _ O w _ ____ 0_ JETRE 0 0 O w oW ______ O K 0 _ ___ 0_ wa 0 i w 0 1 1 0 _____ O K 0 _ ___ O 0 1 O K 0 o 0_ 1 2 1 5 2 7 0 1 1 2 7 34 8 37 254 CD lt N N ag OE Eom X 2012 2012 2012 2012 2012 2012 2012 2012 4 6 saja enna aha oa 262 649 1 622 i a 0 2 2 2 2 4 4 0 0 0 17 81 17 81 0 0 0 7 13 7 13 s u m ow 0 W CM 14 14 0 m O E 5 21 m 21 site 3 W
365. afe jp 7101 0061 1 4 17 03 5217 0252 FAX 03 5217 0253 http www jcqhc or jp 179 No 6 7 No 67 2012 6 2006 2010 sy L No67 2 9 2 4 201 1 l 100 mL A 1 H R 100
366. amel IR Calkins H Berger RD Bluemke DA Halperin HR prospective evaluation of a protocol for magnetic resonance imaging of patients with implanted cardiac devices Ann Intern Med 2011 oct 4 155 7 415 24 9 Advisa MR I FIX MRI 0 3 2 9 4 0 3 2 9 7 0 3 2 9 3 2 4 3 2 9 Online available from lt http www info pmda go jjp mdevices file md2012 0329001 pdf gt last accessed 2012 07 19 116 2 2
367. nese collaboration for Improving Patient safety 2 4 6 5 King s College London Patient Safety and Service Quality Research Centre PSSQ King s College London 2 2 http www dajf org uk news researchers from kings participate in 2nd anglo japanese collaboration event in tokyo for improving patient safety King s College London King s College London
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