医療事故情報収集等事業 第38回報告書
Contents
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207. Potential for Error Procedures and Guidelines A patient presented to emergency complaining of a sore neck and weakness in the right Procedures involving the wrong patient or body part A patient came to emergency with a sudden onset of hemiplegia facial droop and rig Magnetic material e g metal products taken in the MRI r This alert describes two patient safety incidents one causing patient harm as a result of meta Guidewires Left Behind This safety alert addresses the continuing patient safety incidents Title Magnetic material e g metal products taken in the MRI room Topic Diagnostic Imaging Publication Type Medical Safety Information Single or Multiple Incident Multiple Summary This alert describes two patient safety incidents one causing patient harm as a result of metal products which are magnetic being taken into the MRI No 1 UR L No 1 1 Device MRI Date 1 9 2007 Country Japan Organization Japan Council for Quality Health Care Keywords enamel oxygen tank gurney
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271. Alerts Recommendations Country w Organization w Topic Hong Kong Hospital Authority Institute for Safe Medication Practices Canada Japan Council for Quality Health Care Maryland Office of Healthcare Quality USA Minnesota Department of Health USA Errors Involving Drug Related Clinical Monitoring This article discusses the importance of clinical monitoring Recommendations Country w Organization w Topic w a England and Wales Hong Kong United Kingdom United States of America Errors Involving Drug Related Clinical Monitoring This article discusses the importance of clinical monitoring MRI Alerts Recommendations Country w Organization w Topic w Review of Imaging Process Errors and Potential Solution Diagnostic imaging plays an important role in patient care Improvements in imaging modali Learning from Low or No Harm Events In this Patient Safety Topic three close calls of patient safety incidents were reviewed In one Changing technology changing risk Upgrading fro A ventilator was pulled into the 34 MR 1 No 1 0 MR 1
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428. View Full Alert http www med safe jp pdf No Safety information Project to Co ect Meaca Near Mess Adverse Event information No 10 September 2007 Th Japan Council for Quality Health Care 5 10 September 2007 Magnetic material e g metal products taken in the MRI room Two accidents involvi iu magnetic mat metal products taken the MRI collect uade cto 3 200115 March 31 2007 e information is partly in Medical Adverse Event Information to Be Shared in the S otk Quae Pagar Ensuring a thorough system to prevent patients and healthcare providers from taking magnetic materials e g metal products into the MRI room is necessary Magnetic materials e g metal products taken into the MRI room which caused accidents Oxygen tank Enamel tray Enamel products are made of metal and glass and therefore magnetic attracted by magnetic substances 35 5 1 AP International Accreditation Programme SQua I A P Internatioal Accreditation Programme 32 UK Lic Ver 4 0 Ver 5 0
429. amp x m x Printer Friendly Online Store Sharing for Learning Emailto a Friend ME Get Updates Patient identifcation Browse All Interested in what you might find in Global Patiegt Safety Alerts Easily opic area below ALERTS BROWSE ALL RECOMMENDATIONS BROWSE ALL Air Embolism Bed Rail festraint Air Embolism Bed Rail Restraint Blood Products Transfusion Care Mangement Blood Products Transfusion Care Management Clinical Administration Documentation Device Clinical Administration Documentation Device Diagnostic Imaging EnvironmWntal Diagnostic Imaging Environmental Falls Infection Qontrol Falls Infection Control Medical Gas Medicatio Medical Gas Medication Neonatal Paediatric Obstetri abour and Delivery Neonatal Paediatric Obstetrics Labour and Delivery Other Other Patient Identification Patient Protection Pressure Dicer Patient Protection Pressure Ulcer Specimen Laboratory Suicide Specimen Laboratory Suicide Surgery Surgery Blood tranbfusion to wrong patient Japan Cound for Quality Health Care This alert dispusses patient safety incidents where blood transfusions have been administered to the wrong patient Eight incidents were reported from October 1 2004 to June 30 2007 Six ofthe cases reported were cases in which the blood productto be used on the patient wis not finally checked when connecting blood product for transfusion use In five out of six reported cases the blood pr
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445. System Seal European Union European Union Network for Patient Safety Hong Kong Hong Kong Hospital Authority Risk Alert Newsletter Japan Japan Council for Quality Health Care Medical Safety Information United States of America California Hospital Patient Safety Organization Newsletters and Alerts 31 16 Global Patient Safety Alerts Sharing for Learning BROWSE ALL CONTRIBUTING ABOUT EATI j m ey Q Printer Friendly Online Store Emailto aFriend 82 Get Updates Global Patient Safety Alerts a lt B SOLUTIONS TO PROBLEMS THAT HAVE ALREADY BEEN SOLVED HOSPITAL NEWS CLICK Hi MRI EAJ Alerts Recorg mendations Find alerts advisorie and recommendations from patient safety quality and healthcare organizations from apund the world Procedures involying the wrong patient or body part Victoria Department o Health Australia A patient came to emergency with a sudden onset of hemiplegia facial droop and right sided weakness CT ofthe brain showed a large frontal hemorrage and cerebral edema with no midline shift After discussions with the patient and family it was decided to manage thd patient surgically The consultant left the theatre during the set up and instructed the registrar to start the case When the consulant returned the registrar had started the incision
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449. to the MRI device in order to move the patient to the platform the oxygen tank flew out and stuck to the MRI gantry In the other case a nurse prepared a sedative for a child undergoing MRI and put the sedative into an enamel tray and left it in the anteroom adjacent to the MRI room The clinical radiologist took the tray from the anteroom into the MRI room putit on the platform near the child s feet and started the sedation procedure When the child was asleep the platform was moved to the head ofthe MRI device to start scanning The enameled tray placed close to the child s feet was pulled towards the MRI gantry the used articles in the tray flew out and some ofthe articles hitthe child which caused a laceration in the child s mouth September 2007 Q hfety incidents occurring due to retained surgical items Several of the No 1 0 erization Retained guidewires are typically retrieved via a percutaneous i h could occur if the guidewire is not retrieved include the following M cardiac arrhythmias retained guidewire act as microwave RE 32 IMPROVING CARE can ps fe J e COMMUNITIES SEARCH CENTRE lt of PRACTICE b Contact Fran ais NEWS BROWSE ALL CONTRIBUTING ORGANIZATIONS TOOLS amp RESOURCES Search gt Browse All
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452. 2 SEARCH CENTRE ABOUT CPSI RESEAI CH cpsi ICsp Safe care accepting no less Canadian Patient Safety Inbti NEWS Prairie Mountain Health develops Quality and Patient Safety Education program Sayonara to infections April is Canadian Hand Hygiene Audit month DIGITAL MAGAZINE SUBSCRIBE NOW y New standards for nursing education programs promote patient safety competencies National healthcare organizations Z IMPROVING CARE 5 cps voee amy Y SEARCH CENTRE lt lt E now m GLOBAL PATIENT gt Search Sharing for Learning Global Patient Safety Alerls Search Japan Australia Canada Denmark Hong Kong England and Wales European Union United States sy A COMMUNITIES of PRACTICE Careers Contact Francais EDUCATION TOOLS amp RESOURCES NEWS amp EVENTS Bands SN Printer Friendly V7 Online Store Emailto a Friend WE Get Updates DIGITAL MAGAZINE Patient Safety Oflicer Course PATIENT SAFETY FORV ARD WITH FOUR Check out the latest issue of e Patient Safety GPSA FEATUREDALERT Forward with Four COMMUNITIES of PRACTICE m Contact Francais Enns Printer Friendly X 7 Online Store EmailtoaFriend mz Get Updates n Dow Tm App Store EUNetPas Share Learn and Exchange
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468. nferences gt gt Tokyo 2016 TOKYO 2016 Programme ISQua s 33 International Conference es Tokyo International Forum Japan Registration iic m gt 16 19w October 2016 Plenary Speakers Kd Seales Tokyo International Forum Tokyo Japan 2016 Scholarship ISQua s 33rd International Conference will be held in Tokyo s International Forum Each year ISQua Call for Papers brings delegates together from across the world to hear from leaders in their field share their expertise and knowledge through a multidisciplinary forum including scientific sessions and networking social Sponsorship events Programme and Planning Venue Tokyo International Forum Tokyo Japan Committee Venue amp General Information HAL Career Achievement Prize Future Conferences Future Conferences Tokyo International Forum Website Doha 2015 Tokyo International Forum Website 37 7 4 0 8
469. oduct usedWor transfusion was c ed with the transfusion sheet or medical chart etc atthe nurse s station butthe blood product was not checked against the patient In one of the two cases described in detail the physician was called away for another patient s treatment whle preparing the blood product for transfusion to 2 patients Patient C and Patient D Thirty minutes later the physician moved to perform the transfusion to Patient C placed blood product for transfusion to Patient D in the tray went to Patient C s room and connectdd the blood product for transfusion without checking if it was for Patient C Later the physician noticed that he had connected D s transfusion blood product to Patient C because Patient C s w ll left unconnected Patient mix up during medical examination Japan Council for Quality Health Care This alert discussed three patient safety incidents where ineffective verbal confirmation of the patients name was used In all three s the patients name was confirmed by calling out the name and allowing the patient to answer Yes or One incident is described where patient was called into the outpatient examination room Patient B answered yes to the name called and entered the examination room for the procedure After the examination was finished a nurse called for patient B The patient who had been already examined as patient A actually patient B entered the room again so the staff noticed the pa
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471. the wrong side The outcome for the patient was an extended incision line Pontributing factors included final time out checks were not completed lack of preoperative marking and final check of the patients images were not performed Patient 1 went to radiology for an outpatient abdominal MRI On responding to a call fof another patient Patient 1 underwent pre and post contrast scans and then told staff that they were not referring to him by his fiame At the same time Patient 2 s wife told staff that her husband had already gone in when his name was called A confirmation of the identity of both patients was undertaken and the correct MRI scans completed Contributing factors included there was no confirmation of patient identity as per best practice and the selection of the wrong patient remained undetected que to a number of factors This alert describes actions to reduce risk July 2009 Magnetic material e g metal products taken in the MRI room Japan Council for Quality Health Care This alert describes two patient safety incidents one causing patient harm as a result of metal products which are magnetic being taken into the MRI room and not removed once the MRI has commenced In one case a patient on oxygen was taken into the MRI room on a gurney from the emergency room A clinical radiologist thought the gurney and the oxygen tank were for exclusive use in the MRI room and did not check their identification When the gurney was moved close
472. tient mix up December 2008 Catheterization was Performed on the Wrong Patie Hong Kong Hospital Authority This safety alert describes a patient safety incident wh J C Q H C NO 2 5 identification A urinary catheter was removed from Patient E nurse was on her way to patient A s home to perform blac BO BBA elderly lady a panied by a domestic helper near the res The elderly lady responded positively so the nurse followed the elderly lady and her domestic helper back to her home for bladder catheterization There was no further verification ofthe patients identity en the nurse could not find any urinary drainage bag in the elderly lad she contacted a relative of patient A to confirm the identity of the elderly lady It was discovered that the elderly lady was not patient A The elderly lady did not have any adverse outcome A contributing factor to the incident was that patient identification 33 17 Global Patient Safety Alerts Canadian Patient Safety Institute JN GLOBAL PATIENT SAFETY x Sharing for Learning Recommendations Global Patient Safety Alerts is an innovative information sharing resource to help you prevent and mitigate patient safety incidents in your organization and help others succeed
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