A Method of Planning Countermeasures for Medication Incidents from the Viewpoint of

(1)

᪩ ✄ ⏣ ኱ Ꮫ ኱ Ꮫ 㝔 ๰ 㐀 ⌮ ᕤ Ꮫ ◊ ✲ ⛉

༤ ༤ 㻌 ኈ 㻌 ㄽ 㻌 ᩥ 㻌 ᴫ 㻌せ

ㄽ ᩥ 㢟 ┠

ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ࡳ ࡓ

୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࡟ 㛵 ࡍ ࡿ ◊ ✲

A Method of Planning Countermeasures for Medication Incidents from the Viewpoint of

Standard Operation Procedures

⏦ ㄳ ⪅

㔠 ᾏ ဴ

Haizhe JIN

⤒ Ⴀ ࢩ ࢫ ࢸ ࣒ ᕤ Ꮫ ᑓ ᨷ ရ ㉁ ࣐ ࢿ ࢪ ࣓ ࣥ ࢺ ◊ ✲

2 0 1 3 ᖺ 5 ᭶

(2)

19 99 ᖺ ࡟ Ⓨ ⏕ ࡋ ࡓ ᶓ ὾ ᕷ ❧ ኱ Ꮫ ௜ ᒓ ⑓ 㝔 ࡢ ᝈ ⪅ ྲྀ ࡾ 㐪 ࠼ ஦ ᨾ ࢆ ࡣ ࡌ ࡵ ࡜

ࡋ ࡚ 㸪1 9 9 9 ᖺ ࠿ ࡽ 2 0 00 ᖺ ࡟ ࠿ ࡅ ࡚ ࠸ ࡃ ࡘ ࠿ ࡢ 㔜 ኱ ་ ⒪ ஦ ᨾ ࡀ Ⓨ ⏕ ࡋ ࡓ 㸬 ࡇ ࢀ ࢆ ዎ ᶵ ࡟ 㸪་ ⒪ ஦ ᨾ ࡟ ᑐ ࡍ ࡿ ♫ ఍ ࡢ 㛵 ᚰ ࡀ 㧗 ࡲ ࡾ 㸪ཌ ⏕ ປ ാ ┬ ࡛ ࡣ 㸪་

⒪ ࡟ ࠾ ࡅ ࡿ Ᏻ ඲ ☜ ಖ ࢆ ་ ⒪ ᨻ ⟇ ࡟ ࠾ ࡅ ࡿ 㔜せㄢ㢟 ࡜ ఩ ⨨ ࡙ ࡅ 㸪ᵝ ࠎ ࡞ ᪋ ⟇ ࢆ

࡜ ࡗ ࡚ ࡁ ࡓ 㸬 ࡲ ࡓ 㸪 ྛ ་ ⒪ ᶵ 㛵 ࡛ ࡣ 㸪 ་ ⒪ Ᏻ ඲ ࡟ 㛵 ࡍ ࡿ ά ື ࢆ ⟶ ⌮ ࣭ ᥎ 㐍 ࡍ

ࡿ ་ ⒪ Ᏻ ඲ ⟶ ⌮ ⪅ ࢆ 㓄 ⨨ ࡋ 㸪஦ ᨾ ሗ ࿌ ᭩ ࡶ ከ ࡃ ཰ 㞟 ࡉ ࢀ ࡿ ࡼ ࠺ ࡟ ࡞ ࡗ ࡓ 㸬ࡋ

࠿ ࡋ 㸪ࡑ ࡇ ࠿ ࡽ ᚓ ࡽ ࢀ ࡓ ᝟ ሗ ࢆ ຠ ᯝ ⓗ ࡟ ά ࠿ ࡍ ࡇ ࡜ ࡀ ࡛ ࡁ ࡎ 㸪஦ ᨾ ሗ ࿌ ᭩ ࢆ

཰ 㞟 ࡍ ࡿ ࢩ ࢫ ࢸ ࣒ ࡀ 㸪་ ⒪ ஦ ᨾ ࢆ ప ῶ ࡍ ࡿ ࡓ ࡵ ࡟ ᭷ ຠ ࡟ ᶵ ⬟ ࡋ ࡚ ࠸ ࡞ ࠸ ࡢ ࡀ

⌧ ≧ ࡛ ࠶ ࡿ 㸬

་ ⒪ ஦ ᨾ ࡢ ୰ ࡛ ࡣ ୚ ⸆ ஦ ᨾ ࡀ 㧗 ࠸ ๭ ྜ ࢆ ༨ ࡵ ࡚ ࠾ ࡾ 㸪୚ ⸆ ஦ ᨾ ࡟ ࡼ ࡾ ᝈ ⪅ ࡀ Ṛ ஸ ࡍ ࡿ ࡞ ࡝ 㔜 ኱ ࡞ ⤖ ᯝ ࢆ ᘬ ࡁ ㉳ ࡇ ࡋ ࡚ ࠸ ࡿ 㸬࡞ ࠾ 㸪ᮏ ◊ ✲ ࡛ ࡣ 㸪 ண ᐃ ࡋ

࡚ ࠸ ࡓ ୚ ⸆ ࡢ ⤖ ᯝ ࡜ ᐇ 㝿 ࡢ ୚ ⸆ ࡢ ⤖ ᯝ ࡜ ࡢ 㛫 ࡟ ᕪ ␗ ࡀ ࠶ ࡿ ࡇ ࡜ ࢆ ୚ ⸆ ஦ ᨾ

࡜ ࡋ ࡚ ᤊ ࠼ ࡿ 㸬ࡇ ࡇ ࡛ ࡢ ୚ ⸆ ࡢ ⤖ ᯝ ࡜ ࡣ 㸪┳ ㆤ ᖌ ࡀ ୚ ⸆ ࡍ ࡿ ᝈ ⪅ ྡ 㸪㑅 ᢥ ࡍ

ࡿ ⸆ ๣ ࡢ ✀ 㢮㸪タ ᐃ ࡍ ࡿ ⸆ ๣ ࡢ 㔞 ࡞ ࡝ ࢆ ᣦ ࡋ ࡚ ࠸ ࡿ 㸬ࡲ ࡓ 㸪୚ ⸆ ᴗ ົ ࡟ ࡣ ་ ᖌ 㸪⸆ ๣ ᖌ 㸪┳ ㆤ ᖌ ࡞ ࡝ 」 ᩘ ࡢ ⫋ ✀ ࡀ 㛵 ࢃ ࡿ ࡀ 㸪ᮏ ◊ ✲ ࡛ ࡣ ┳ ㆤ ᖌ ࡢ ୚ ⸆ ẁ 㝵 ࢆ ᑐ ㇟ ࡟ ࡋ ࡚ ࠸ ࡿ 㸬

୚ ⸆ ஦ ᨾ ࡢ 㜵 Ṇ ⟇ ࡜ ࡋ ࡚ ࡣ ᵝ ࠎ ࡞ ࡶ ࡢ ࡀ ⪃ ࠼ ࡽ ࢀ ࡿ ࡀ 㸪୚ ⸆ ᴗ ົ ࡣ ᶆ ‽ ᡭ 㡰 ࡀ ᐃ ࡵ ࡽ ࢀ ࡚ ࠾ ࡾ 㸪ࡑ ࢀ ࡟ ᚑ ࡗ ࡚ స ᴗ ࢆ ⾜ ࠺ ࡇ ࡜ ࡀ ୍ ⯡ ⓗ ࡛ ࠶ ࡾ 㸪࢚ ࣛ ࣮ ࡀ Ⓨ ⏕ ࡋ ࡟ ࡃ ࠸ ᶆ ‽ ᡭ 㡰 ࡟ ࡍ ࡿ ࡇ ࡜ ࡀ ᭷ ຠ ࡛ ࠶ ࡿ 㸬

ࡋ ࠿ ࡋ 㸪ᶆ ‽ ᡭ 㡰 ࢆ ᏶ ⎍ ࡟ స ᡂ ࡍ ࡿ ࡇ ࡜ ࡣ 㞴 ࡋ ࡃ 㸪ᶆ ‽ ᡭ 㡰 ࡢ ఱ ࡽ ࠿ ࡢ ୙ ල ྜ ࡟ ࡼ ࡾ ஦ ᨾ ࡀ Ⓨ ⏕ ࡋ ࡚ ࠸ ࡿ 㸬ࡑ ࡢ ࡓ ࡵ 㸪ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ஦ ᨾ ࢆ ศ ᯒ ࡋ 㸪ᑐ ⟇ ࢆ ❧ ᱌ ࡍ ࡿ ࡇ ࡜ ࡣ 㔜せ ࡛ ࠶ ࡿ ࡀ 㸪ࡑ ࡢ ල య ⓗ ࡞ ᪉ ἲ ࡣ ࡲ ࡔ ☜ ❧ ࡉ ࢀ

࡚ ࠸ ࡞ ࠸ ࡢ ࡀ ⌧ ≧ ࡛ ࠶ ࡿ 㸬 ࡓ ࡜ ࠼ ࡤ 㸪 ᮏ ◊ ✲ ࡢ ༠ ຊ ⑓ 㝔 ࡛ ࠶ ࡿ A ⑓ 㝔 ࡢ ་

⒪ ᚑ ஦ ⪅ ࡀ 㸪3 ࣨ ᭶ 㛫㸦2 0 07 ᖺ 1 ᭶ 㹼3 ᭶ 㸧࡛ ࡢ ୚ ⸆ ஦ ᨾ ࡟ ᑐ ࡋ ࡚ ❧ ᱌ ࡋ ࡓ ᑐ ⟇ 7 4 ௳ ࢆ ศ ᯒ ࡋ ࡓ ⤖ ᯝ 㸪 ஦ ᨾ ᙜ ஦ ⪅ ࡟ ᑐ ࡍ ࡿ ὀ ព ࡸ ⑓ Ჷ ෆ ࡛ ࡢ ஦ ᨾ ෆ ᐜ ࡢ ࿘ ▱ ࡞ ࡝ 㸪ே ࡢ ὀ ព ຊ ࡟ 㢗 ࡿ ᑐ ⟇ ࡀ 8 ๭ ௨ ୖ ࢆ ༨ ࡵ ࡚ ࠸ ࡓ 㸬ࡇ ࡢ ࡼ ࠺ ࡞ ே ࡢ ὀ ព ຊ ࡟ 㢗 ࡿ ᑐ ⟇ ࡣ 㸪ே 㛫 ࡢ ≉ ᛶ ࡸ స ᴗ ࡢ ≉ ᛶ ࡀ ⪃ ៖ ࡉ ࢀ ࡚ ࠾ ࡽ ࡎ 㸪ᑐ ⟇ ࡢ ຠ ᯝ ࡀ ᣢ ⥆ ࡋ ࡞ ࠸ 㸬ࡑ ࡢ ࡓ ࡵ 㸪་ ⒪ ⌧ ሙ ࡛ ᑐ ⟇ ࡀ ຠ ᯝ ⓗ ࡟ ❧ ᱌ ࡛ ࡁ ࡚ ࠸ ࡞

࠸ ⌮ ⏤ ࢆ ㄪ ᰝ ࡍ ࡿ ࡜ ࡜ ࡶ ࡟ 㸪ຠ ᯝ ⓗ ࠿ ࡘ ຠ ⋡ ⓗ ࡟ ᑐ ⟇ ࢆ ❧ ᱌ ࡛ ࡁ ࡿ ᪉ ἲ ࢆ 㛤

Ⓨ ࡍ ࡿ ࡇ ࡜ ࡣ 㸪㔜せ ࡞ ㄢ㢟 ࡛ ࠶ ࡿ 㸬

ࡑ ࡇ ࡛ 㸪ᮏ ◊ ✲ ࡛ ࡣ 㸪୚ ⸆ ᴗ ົ ࡢ ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ࡳ ࡓ 㸪୚ ⸆ ஦ ᨾ ࡢ ᑐ

⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ ࡇ ࡜ ࢆ ┠ ⓗ ࡜ ࡍ ࡿ 㸬ᮏ ◊ ✲ ࡛ ࡣ 㸪୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌

࡟ ᚲ せ ࡞ ୍ 㐃 ࡢ ࢶ ࣮ ࣝ ࢆ 㛤 Ⓨ ࡍ ࡿ ࡜ ࡜ ࡶ ࡟ 㸪ࡇ ࢀ ࡽ ࡢ ࢶ ࣮ ࣝ ࢆ ⏝ ࠸ ࡓ ᑐ ⟇ ❧

᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬

ᮏ ◊ ✲ ࡛ ࡣ 㸪་ ⒪ ஦ ᨾ ࡟ 㛵 ࡍ ࡿ ࡇ ࢀ ࡲ ࡛ ࡢ ື ྥ 㸪㛵㐃 ࡍ ࡿ ᚑ ᮶ ◊ ✲ 㸪࠾ ࡼ ࡧ ⑓ 㝔 ࡟ ࠾ ࡅ ࡿ ୚ ⸆ ᴗ ົ ࡸ ୚ ⸆ ஦ ᨾ ࡢ ศ ᯒ 㸪 ᑐ ⟇ ❧ ᱌ ࡢ ⌧ ≧ ࢆ ㄪ ᰝ ࡋ 㸪 ᚑ

No . 1

(3)

᮶ ࡢ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࡟ ࠾ ࡅ ࡿ ၥ 㢟 Ⅼ ࢆ ᢕ ᥱ ࡍ ࡿ 㸬ࡲ ࡓ 㸪ᶆ ‽ ᡭ 㡰 ࡀ Ꮡ ᅾ ࡍ ࡿ ࡜ ࡁ ࡟ 㸪ᶆ ‽ ᡭ 㡰 ࢆ ᐇ ᪋ ࡋ ࡞ ࠿ ࡗ ࡓ ሙ ྜ ࡜ ᐇ ᪋ ࡋ ࡓ ሙ ྜ ࡢ ஧ ࡘ ࡢ ஦ ᨾ Ⓨ

⏕ ⤒ ㊰ ࡀ ࠶ ࡿ ࡜ ࠸ ࠺ ஦ ᨾ Ⓨ ⏕ ⤒ ㊰ ࣔ ࢹ ࣝ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬ࡑ ࡋ ࡚ 㸪ࡑ ࡢ ࣔ ࢹ ࣝ ࡟

ࡶ ࡜ ࡙ ࠸ ࡚ ၥ 㢟 Ⅼ ࢆ ゎ Ỵ ࡍ ࡿ ࡓ ࡵ ࡟ 㸪୚ ⸆ ஦ ᨾ ࡟ ᑐ ࡍ ࡿ ᭷ ຠ ࡞ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࡢ ௙ ᵝ ࢆ ḟ ࡢ ࡼ ࠺ ࡟ ᐃ ࡵ ࡿ 㸬

(1 ) ࣉ ࣟ ࢭ ࢫ ᣦ ྥ ࡜ ࡞ ࡿ ࡼ ࠺ ࡟ 㸪ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ⪃ ࠼

ࡿ 㸬ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ࡳ ࡓ ሙ ྜ 㸪஦ ᨾ Ⓨ ⏕ ⤒ ㊰ ࣔ ࢹ ࣝ ࡀ ஦ ᨾ ࡢ Ⓨ ⏕ ⤒ ㊰ ࢆ

⥙ ⨶ ࡋ ࡚ ࠸ ࡿ ࡢ ࡛ 㸪 ࡑ ࢀ ࡟ ᚑ ࡗ ࡚ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ⪃ ࠼ ࡿ 㸬

(2 ) ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࡣ 㸪 ་ ⒪ ⌧ ሙ ࡟ ࠾ ࠸ ࡚ 㸪 ┳ ㆤ ᖌ 㛗 ࡸ ๪ ᖌ 㛗㸪 ୺ ௵

࡞ ࡝ ࡢ ་ ⒪ Ᏻ ඲ ⟶ ⌮ ⪅ ࡀ ⾜ ࠺ ࡇ ࡜ ࡀ ከ ࠸ ࡇ ࡜ ࠿ ࡽ 㸪ᥦ ᱌ ᪉ ἲ ࡢ ฼ ⏝ ᑐ ㇟ ⪅ ࡜ ࡋ ࡚ ་ ⒪ Ᏻ ඲ ⟶ ⌮ ⪅ ࢆ ᝿ ᐃ ࡍ ࡿ 㸬

(3 ) ᥦ ᱌ ᪉ ἲ ࡣ 㸪 ᑐ ⟇ ❧ ᱌ ࡢ Ⓨ ᝿ ࢆ ᚑ ᮶ ᪉ ἲ ࡼ ࡾ ᐜ ᫆ ࡟ ࡍ ࡿ ࡓ ࡵ 㸪 ᑐ ⟇ ❧

᱌ ẁ 㝵 ࡟ ࠾ ࠸ ࡚ ᚲ せ ࡞ ࢶ ࣮ ࣝ ࢆ ண ࡵ 㛤 Ⓨ ࡍ ࡿ 㸬

(4 ) ᑐ ⟇ ᱌ ࡢ ෆ ᐜ ࡣ ὀ ព ႏ ㉳ ࡸ ࿘ ▱ ᚭ ᗏ ࡛ ࡣ ࡞ ࡃ 㸪஦ ᨾ ࡢ ෌ Ⓨ 㜵 Ṇ ࡟ ᭷ ຠ

࡞ ᑐ ⟇ ᱌ ࡜ ࡞ ࡿ ࡼ ࠺ ࡟ ࡍ ࡿ 㸬ࡇ ࡇ ࡛ ࡢ ᭷ ຠ ᛶ ࡣ 㸪ᑐ ⟇ ᱌ ࡢ ᩘ ࠾ ࡼ ࡧ ࡑ ࡢ ල య ᛶ ࡜ ከ ᵝ ᛶ ࡛ ホ ౯ ࡍ ࡿ 㸬

(5 ) ་ ⒪ ⌧ ሙ ࡢ ≉ ᚩ ࡟ ࡼ ࡾ 㸪ᑐ ⟇ ❧ ᱌ ࡟ ࠿ ࡅ ࡽ ࢀ ࡿ ᫬ 㛫 ࡀ 㝈 ࡽ ࢀ ࡚ ࠸ ࡿ ⌧

≧ ࡀ ࠶ ࡾ 㸪 ᥦ ᱌ ᪉ ἲ ࡣ 㸪 ຠ ⋡ ⓗ ࡟ ᑐ ⟇ ࢆ ❧ ᱌ ࡛ ࡁ ࡿ ࡼ ࠺ ࡟ ࡍ ࡿ 㸬

ୖ グ ࡢ 㛤 Ⓨ ௙ ᵝ ࡟ ࡶ ࡜ ࡙ ࡁ 㸪 ᮏ ◊ ✲ ࡛ ࡣ 㸪 ஦ ᨾ Ⓨ ⏕ ⤒ ㊰ ࣔ ࢹ ࣝ ࡟ ἢ ࡗ ࡚ 㸪 ࠕ ᶆ ‽ ᡭ 㡰 ୙ ᐇ ᪋ ࠖ ࡢ ሙ ྜ ࡜ ࠕ ᶆ ‽ ᡭ 㡰 ᐇ ᪋ ࠖ ࡢ ሙ ྜ ࡟ ศ ࡅ ࡚ 㸪 ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬

ᶆ ‽ ᡭ 㡰 ୙ ᐇ ᪋ ࡟ 㛵 ࡋ ࡚ ࡣ 㸪ࡲ ࡎ 㸪୙ ᐇ ᪋ ࡟ ࡼ ࡾ Ⓨ ⏕ ࡍ ࡿ ஦ ᨾ ࡢ ࣓ ࢝ ࢽ ࢬ

࣒ ࢆ ᫂ ࡽ ࠿ ࡟ ࡍ ࡿ 㸬ࡑ ࡋ ࡚ 㸪୚ ⸆ ᴗ ົ ୰ ࡟ ࠶ ࡾ ࠺ ࡿ 㸪୙ ᐇ ᪋ ࣓ ࢝ ࢽ ࢬ ࣒ ࡢ ᵓ ᡂ せ ⣲ ࡛ ࠶ ࡿ ⾜ ື ㄏ Ⓨ せ ᅉ 㸪୙ ᐇ ᪋ ⾜ ື ≉ ᛶ 㸪஦ ᨾ ㄏ Ⓨ せ ᅉ ࢆ ᢳ ฟ ࡍ ࡿ 㸬ࡲ

ࡓ 㸪୙ ᐇ ᪋ ࣓ ࢝ ࢽ ࢬ ࣒ ࡟ ࡶ ࡜ ࡙ ࡁ 㸪୙ ᐇ ᪋ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࡢ ほ Ⅼ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬

᭱ ᚋ ࡟ 㸪ࡇ ࢀ ࡽ ࡢ ࢶ ࣮ ࣝ ࢆ ⏝ ࠸ ࡚ ᶆ ‽ ᡭ 㡰 ୙ ᐇ ᪋ ᫬ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡋ 㸪 ࡑ ࡢ ᭷ ຠ ᛶ ࡜ ຠ ⋡ ᛶ ࢆ ☜ ㄆ ࡍ ࡿ 㸬

ᶆ ‽ ᡭ 㡰 ᐇ ᪋ ࡟ 㛵 ࡋ ࡚ ࡣ 㸪࢚ ࣛ ࣮ ࣉ ࣝ ࣮ ࣇ ໬ ࡢ ᑐ ⟇ ࡢ ᑐ ㇟ ࡜ ࡞ ࡾ ࠺ ࡿ ୚ ⸆ ᴗ ົ ୰ ࡢ せ ⣲ ࢆ ᨵ ၿ ᑐ ㇟せ ⣲ ࡜ ࡋ ࡚ ᢳ ฟ ࡋ 㸪ྛ ஦ ᨾ ஦ ౛ ࡟ ᑐ ࡋ ࡚ 㸪࢚ ࣛ ࣮ せ ᅉ ࢆ ᘬ ࡁ ㉳ ࡇ ࡋ ࡓ ᨵ ၿ ᑐ ㇟せ ⣲ ࢆ ิ ᣲ ࡍ ࡿ ᪉ ἲ ࡜ ࡋ ࡚ ᨵ ၿ ᑐ ㇟せ ⣲ ᢳ ฟ ࢩ

࣮ ࢺ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬ࡉ ࡽ ࡟ 㸪ྛ ᨵ ၿ ᑐ ㇟せ ⣲ ࡟ ᑐ ࡋ ࡚ ࢚ ࣛ ࣮ ࣉ ࣝ ࣮ ࣇ ໬ ࡢ ᑐ ⟇

❧ ᱌ ࢆ ᐜ ᫆ ࡟ ࡍ ࡿ ࡓ ࡵ ࡟ 㸪ᑐ ⟇ Ⓨ ᝿ ほ Ⅼ ࣜ ࢫ ࢺ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬᭱ ᚋ ࡟ 㸪ࡇ ࢀ ࡽ ࡢ ࢶ ࣮ ࣝ ࢆ ⏝ ࠸ ࡚ ᶆ ‽ ᡭ 㡰 ᐇ ᪋ ᫬ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡋ 㸪ࡑ ࡢ ᭷ ຠ ᛶ ࡜ ຠ

⋡ ᛶ ࢆ ☜ ㄆ ࡍ ࡿ 㸬

ᮏ ◊ ✲ ࡛ ࡣ 㸪ୖ ㏙ ࡢ ஧ ࡘ ࡢ ᪉ ἲ ࢆ ࡲ ࡜ ࡵ ࡚ 㸪ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ࡳ ࡓ ୚ ⸆

஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࡜ ࡋ ࡚ ᥦ ᱌ ࡍ ࡿ 㸬ᥦ ᱌ ᪉ ἲ ࡣ 㸪་ ⒪ ⌧ ሙ ࡢ ≉ ᚩ ࢆ ⪃ ៖ ࡋ 㸪 No . 2

(4)

▷ ᫬ 㛫 ࡛ ຠ ᯝ ⓗ ࡞ ᑐ ⟇ ᱌ ࢆ ❧ ᱌ ࡛ ࡁ ࡿ ࡼ ࠺ ࡟ ᥦ ᱌ ࡍ ࡿ 㸬ࡲ ࡓ 㸪ᑐ ⟇ ❧ ᱌ ࡟ ⏝

࠸ ࡿ ୍ 㐃 ࡢ ࢶ ࣮ ࣝ ࡢ 㛤 Ⓨ ࡟ ࡼ ࡾ 㸪ᑐ ⟇ ❧ ᱌ ࡢ ⤖ ᯝ ࡣ 㸪ศ ᯒ ⪅ ࡢ ⤒ 㦂 ࡸ ᛮ ⪃ ࡟ ጤ ࡡ ࡽ ࢀ ࡿ 㒊 ศ ࡀ ᑡ ࡞ ࡃ ࡞ ࡿ ࡜ ⪃ ࠼ ࡽ ࢀ ࡿ 㸬௨ ୖ ࡢ ࡇ ࡜ ࢆ ᐇ ⌧ ࡍ ࡿ ࡇ ࡜ ࡟ ࡼ

ࡾ 㸪ᥦ ᱌ ᪉ ἲ ࡣ ་ ⒪ ࡟ ᐜ ᫆ ࡟ 㐺 ⏝ ࡛ ࡁ ࡿ ࡜ ⪃ ࠼ ࡽ ࢀ 㸪ᥦ ᱌ ᪉ ἲ ࡟ ࡼ ࡗ ࡚ ᶆ ‽ ᡭ 㡰 ࢆ ࡼ ࡾ Ⰻ ࡃ ᨵ ၿ ࡋ ࡚ ࠸ ࡃ ࡇ ࡜ ࡀ ྍ ⬟ ࡟ ࡞ ࡿ ࡜ ⪃ ࠼ ࡽ ࢀ ࡿ 㸬

ᮏ ㄽ ᩥ ࡣ 㸪 ௨ ୗ ࡟ ♧ ࡍ 8 ❶ ࠿ ࡽ ᵓ ᡂ ࡉ ࢀ ࡿ 㸬

➨ 1 ❶ ࡛ ࡣ 㸪 ◊ ✲ ࡢ ⫼ ᬒ ࢆ ㏙ ࡭ 㸪 ᮏ ◊ ✲ ࡢ ┠ ⓗ ࢆ ♧ ࡍ 㸬

➨ 2 ❶ ࡛ ࡣ 㸪ࡲ ࡎ 㸪ᮏ ◊ ✲ ࡢ ࣋ ࣮ ࢫ ࡜ ࡞ ࡿ ஦ ᨾ Ⓨ ⏕ ⤒ ㊰ ࣔ ࢹ ࣝ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬 ḟ ࡟ 㸪ࡇ ࡢ ࣔ ࢹ ࣝ ࢆ ࣋ ࣮ ࢫ ࡟ 㸪㛵㐃 ࡍ ࡿ ᚑ ᮶ ᪉ ἲ 㸪୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࡢ ⌧

≧ ㄪ ᰝ ࢆ ⾜ ࠺ 㸬ࡑ ࡋ ࡚ 㸪ᚑ ᮶ ◊ ✲ ࡸ ⌧ ≧ ㄪ ᰝ ࡢ ⤖ ᯝ ࡟ ࡼ ࡾ 㸪ᥦ ᱌ ᪉ ἲ ࡢ 㛤 Ⓨ

௙ ᵝ ࢆ Ỵ ᐃ ࡋ 㸪 ᮏ ◊ ✲ ࡢ ఩ ⨨ ࡙ ࡅ ࡟ ࡘ ࠸ ࡚ ㏙ ࡭ ࡿ 㸬

➨ 3 ❶ ࡛ ࡣ 㸪ᥦ ᱌ ᪉ ἲ ࡢ 㛤 Ⓨ ᪉ ἲ 㸪◊ ✲ ༠ ຊ ⑓ 㝔 ࡢ 㑅 ᐃ ᪉ ἲ ࠾ ࡼ ࡧ ୚ ⸆ ஦ ᨾ ෆ ᐜ ࡢ ㄪ ᰝ ᪉ ἲ 㸪 ᮏ ◊ ✲ ࡛ ⏝ ࠸ ࡿ ⏝ ㄒ ࡢ ᐃ ⩏ ࡟ ࡘ ࠸ ࡚ ㏙ ࡭ ࡿ 㸬

➨ 4 ❶ ࡛ ࡣ 㸪ᶆ ‽ ᡭ 㡰 ୙ ᐇ ᪋ ᫬ ࡢ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࢶ ࣮ ࣝ ࢆ 㛤 Ⓨ ࡋ 㸪ࡑ ࡢ ࢶ ࣮ ࣝ ࢆ ⏝ ࠸ ࡚ ᶆ ‽ ᡭ 㡰 ୙ ᐇ ᪋ ᫬ ࡟ Ⓨ ⏕ ࡍ ࡿ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬 ࡲ ࡓ 㸪 ࡑ ࡢ ᳨ ド ࢆ ⾜ ࠺ 㸬

➨ 5 ❶ ࡛ ࡣ 㸪ᶆ ‽ ᡭ 㡰 ᐇ ᪋ ᫬ ࡢ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ࢶ ࣮ ࣝ ࢆ 㛤 Ⓨ ࡋ 㸪ࡑ ࡢ ࢶ ࣮ ࣝ ࢆ ⏝ ࠸ ࡚ ᶆ ‽ ᡭ 㡰 ᐇ ᪋ ᫬ ࡟ Ⓨ ⏕ ࡍ ࡿ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬 ࡲ ࡓ 㸪 ࡑ ࡢ ᳨ ド ࢆ ⾜ ࠺ 㸬

➨ 6 ❶ ࡛ ࡣ 㸪 ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࣔ ࢹ ࣝ ࢆ ᵓ ⠏ ࡋ 㸪 ➨ 4 ❶ ࡜ ➨ 5 ❶

࡛ ᥦ ᱌ ࡋ ࡓ ᪉ ἲ ࢆ ࡲ ࡜ ࡵ ࡿ ࡇ ࡜ ࡟ ࡼ ࡾ 㸪ᶆ ‽ ᡭ 㡰 ࡢ ど Ⅼ ࠿ ࡽ ࡳ ࡓ ୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࢆ ᥦ ᱌ ࡍ ࡿ 㸬ࡑ ࡋ ࡚ 㸪୚ ⸆ ஦ ᨾ ࡢ ᑐ ⟇ ❧ ᱌ ᪉ ἲ ࡢ ᭷ ຠ ᛶ ࡜ ຠ ⋡ ᛶ 㸪 ᥦ ᱌ ᪉ ἲ ࡟ ᑐ ࡍ ࡿ 㛤 Ⓨ ௙ ᵝ ࡢ ど Ⅼ ࠿ ࡽ ࡢ ⪃ ᐹ ࢆ ⾜ ࠺ 㸬

➨ 7 ❶ ࡛ ࡣ 㸪ᮏ ◊ ✲ ࡢ ព ⩏ 㸪ᥦ ᱌ ᪉ ἲ ࡢ ་ ⒪ ⌧ ሙ ࡛ ࡢ 㐺 ⏝ ⠊ ᅖ ࡟ 㛵 ࡍ ࡿ ⪃ ᐹ 㸪࢚ ࣛ ࣮ 㜵 Ṇ ◊ ✲ ࡟ ࠾ ࡅ ࡿ ᥦ ᱌ ᪉ ἲ ࡢ ព ⩏ 㸪࢚ ࣛ ࣮ ࣉ ࣝ ࣮ ࣇ ໬ ࡢ ᚑ ᮶ ◊ ✲

࡜ ࡢ ẚ ㍑㸪ᑐ ⟇ ࡟ 㛵 ࡍ ࡿ ὀ ព Ⅼ 㸪ᥦ ᱌ ᪉ ἲ ࡢ ᮍ ↛ 㜵 Ṇ ࡬ ࡢ 㐺 ⏝ ࡞ ࡝ ࡟ ࡘ ࠸ ࡚

⪃ ᐹ ࡍ ࡿ 㸬

➨ 8 ❶ ࡛ ࡣ 㸪ᮏ ◊ ✲ ࡛ ᚓ ࡽ ࢀ ࡓ ᡂ ᯝ ࡢ ࡲ ࡜ ࡵ ࡜ 㸪௒ ᚋ ࡢ ㄢ㢟 ࡜ ᒎ ᮃ ࡟ ࡘ ࠸

࡚ ㏙ ࡭ ࡿ 㸬

No . 3

(5)

㹌㹭

᪩

᪩✄⏣኱Ꮫ ༤ኈ㸦ᕤᏛ㸧 Ꮫ఩⏦ㄳ ◊✲ᴗ⦼᭩

Ặྡ 㔠 ᾏဴ ༳

㸦 ᖺ ᭶ ⌧ᅾ㸧

✀㢮ู 㢟ྡࠊ Ⓨ⾲࣭Ⓨ⾜ᥖ㍕ㄅྡࠊ Ⓨ⾲࣭Ⓨ⾜ᖺ᭶ࠊ 㐃ྡ⪅㸦⏦ㄳ⪅ྵࡴ㸧

ㄽᩥ

ᅜ㝿఍㆟

ཱྀ㢌Ⓨ⾲

[1] Haizhe JIN, Masahiko MUNECHIKA, Masataka SANO, Chisato KAJIHARA(2012/11):

“Four Steps to Reduce Medical Incidents”, International Journal of Quality and service Sciences, Vol.4 Iss:4, pp.399-407

[2] 㔠 ᾏဴ࣭Ჷ㏆㞞ᙪ࣭బ㔝㞞㝯࣭㔠Ꮚ㞞᫂(2013/1)㸸ࠕᶆ‽సᴗ᪉ἲࡢ୙㑂Ᏺ࡟㉳ᅉ ࡍࡿ୚⸆஦ᨾࡢศᯒ࣭ᑐ⟇❧᱌᪉ἲ࡟㛵ࡍࡿ◊✲ࠖ㸪ရ㉁㸪Vol.43㸪No.1㸪pp.133-142.

[3] 㔠 ᾏဴ࣭Ჷ㏆㞞ᙪ࣭㔠Ꮚ㞞࣭᫂బ㔝㞞㝯㸸ࠕ୚⸆஦ᨾ࡟ᑐࡍࡿ࢚࣮ࣛࣉ࣮ࣝࣇ໬࡟

㛵ࡍࡿ◊✲㸫ᨵၿᑐ㇟せ⣲࡟╔┠ࡋࡓᑐ⟇❧᱌᪉ἲࡢᥦ᱌㸫ࠖ㸪ရ㉁㸪Vol.43, No.3, In Press

[4] Haizhe JIN, Masahiko MUNECHIKA, Masaaki KANEKO, Masataka SANO(2010/10): “A Study on the Communication Errors in Healthcare”, The 8^th Asian Network for Quality Proceedings(India)

[5] Haizhe JIN, Masahiko MUNECHIKA, Masataka SANO, Chisato KAJIHARA(2011/6): “A study on a method of planning countermeasures by Error-Proofing”, 55^th EOQ, pp14.1.1-14.1.9(Hungary)

[6] Chisato KAJIHARA, Masahiko MUNECHIKA, Masataka SANO, Haizhe JIN(2011/8): “A Study on the Structure of Educational Content for Healthcare Quality and Safety”, 55^th EOQ, pp14.1.1-14.1.9(Hungary)

[7] Haizhe JIN, Masahiko MUNECHIKA, Masaaki KANEKO, Masataka SANO(2011/8): “A Study on the Methodology to Analyse and Prevent Medical Errors due to Non-observance” , The 9^th Asian Network for Quality Proceedings(Vietnam)

[8] Haizhe JIN, Masahiko MUNECHIKA, Masataka SANO, Chisato KAJIHARA(2012/8): “A study on a method of improving working method in healthcare”, The 10^th Asian Network for Quality Proceedings(Hongkong)

[9] Chisato KAJIHARA, Masahiko MUNECHIKA, Masataka SANO, Haizhe JIN(2012/8):

“Proposal of the method to plan education and training for healthcare safety”, The 10^th Asian Network for Quality Proceedings(Hongkong)

[10] Haizhe JIN, Masahiko MUNECHIKA, Masataka SANO, Chisato KAJIHARA(2012/9):

“Four steps to reduce medical incidents”, 15^th QMOD conference on Quality and Service sciences Proceedings(Poland)

[11] Chisato KAJIHARA, Masahiko MUNECHIKA, Masataka SANO, Haizhe JIN(2012/9):

“PROPOSAL OF METHOD FOR PLANNING EDUCATION AND TRAINING IN HEALTHCARE SAFETY”, 15^th QMOD conference on Quality and Service sciences Proceedings(Poland)

[12] Masataka Sano , Masahiko Munechika, Haizhe Jin, Chisato Kajihara(2012/9): “Analysis of Medication Incident for Improvement of Medication Process”, 15^th QMOD conference on Quality and Service sciences Proceedings(Poland)

[13] 㔠 ᾏဴ㸪Ჷ㏆㞞ᙪ㸪㔠Ꮚ 㞞᫂㸪బ㔝㞞㝯(2011/5)㸸͆సᴗ᪉ἲࡢ୙㑂Ᏺ࡟㉳

ᅉࡍࡿ୚⸆஦ᨾࡢศᯒ࣭ᑐ⟇❧᱌᪉ἲ࡟㛵ࡍࡿ◊✲͇㸪᪥ᮏရ㉁⟶⌮Ꮫ఍➨ 95 ᅇ◊

✲Ⓨ⾲఍せ᪨㞟㸪pp165-168

[14] Ლཎ ༓㔛㸪Ჷ㏆㞞ᙪ㸪బ㔝㞞㝯㸪㔠 ᾏဴ(2012/10)㸸͆་⒪Ᏻ඲ᩍ⫱య⣔ࡢ❧

᱌᪉ἲ࡟㛵ࡍࡿ◊✲͇㸪᪥ᮏရ㉁⟶⌮Ꮫ఍➨42ᅇᖺḟ኱఍

A Method of Planning Countermeasures for Medication Incidents from the Viewpoint of

༤

༤ 㻌 ኈ 㻌 ㄽ 㻌 ᩥ 㻌 ᴫ 㻌 せ

ㄽ ᩥ 㢟 ┠

A Method of Planning Countermeasures for Medication Incidents from the Viewpoint of

Standard Operation Procedures

Haizhe JIN

༤ 㻌 ኈ 㻌 ㄽ 㻌 ᩥ 㻌 ᴫ 㻌せ