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1 ISO9001QMS

2

3

4 I 1. 2 EBMEvidence Based Medicine 1

5 TQM To err is a human Don Berwick 7 7 5% 2

6 R&D 2. ISO 9000 ISO 9000 ISO ISO 9001 ISO 9001 ISO 9000 ISO 9001 ISO

7 ISO 9001 ISO 9001 (1995) ISO

8 II

9 Fact Control ( ) PDCA Plan Do Check Act ( ) PDCA PDCA C 6

10 Plan do check action 4 1 Plan Do Check Action : : ( ) 23 Plan Action Check Do 2 7

11 ( ) ( ) 8

12

13 6 10

14 2-2 1 PDCA P D C P A Adverse Event sliplapsemistake 3 11

15 A A

16

17 7 2 1/2A 100ml/4 1/2Aiv ml 1/2A iv Ns ml/4 1/2A Ns 150ml 4 200ml 1/2A 4 100ml 1/2Aiv 4 100ml 100ml ml 14

18 3 [ 1] [ 2] (1) ( etc.) ( etc.) (2) (3) (4)

19 1 inputprocessoutput SHEL SHEL SHEL L L-S L-H L-E L-L 16

20 / / Software Hardware Environment Liveware 8 SHEL SHEL SHEL 17

21 SHEL 1 Soft 2 Hard SHEL

22

23

24 [1] PDCA P 4-3 ISO9000 ISO

25 ISO9000 ISO ISO ISO ISO9001 ISO ISO9001 ISO

26 ISO9001 peer evaluation 1 2 ISO QC QC 1 QC QC

27 [ ] [1] 1985 [2],,, 2002ISO9000 [2000 ] 5. [1] TO ERR IS HUMAN [2] Williams[3] NHEPNominal Human Error Probability HEARTHuman Error Assessment and Reduction Technique HEART 8 NHEP NHEP NHEP

28 [4][5][6][7][8]

29 [4] [5] AFPM Assessment for Fool Proofs in Manufacturing 26

30 [5]

31 ICU

32 TQM ISO9000 [ ] [1], 2000 [2] 1996 [3]J.C.Williams HEARTa proposed method for assessing and reducing human error (1986)in 9th Advance in Reliability Tech. Symp. Univ. of Bradford [4] 1984 Vol.14 No.2, [5] 1985 Vol.15, No.1, [6] Vol.15, No.4, [7] Vol.16, No.1, 4-13 [8] 2002 Vol.32, No.2, [9] 1984 Vol.14, No.2, Vol

33 30

34 one doseunit dose 31

35 ID 32

36 EP 33

37 III ISO ISO9000 ISO ISO ISO :49 :32 :47 : ISO JIS Z ISO9000 ISO ISO9000ISO9001ISO9004 JIS Q 9000JIS Q 9001JIS Q ISO9000 ISO ISO9000JIS Q 9000 ISO9001 JIS Q9001 ISO9004JISQ 9004 ISO

38 ISO ISO9000 JIS Q 9000 ISO9001 JIS Q9001 ISO9004 JISQ 9004 ISO ISO9001 ISO9004 ISO9004 ISO ISO9001 ISO

39

40 ISO

41 ISO9001 what How 3 what how conformity ISO

42 751 how what ISO how 3 ISO9001 ISO ISO

43 1 h ISO9001 ISO9001 Certification Assessment and Registration

44 JAB,,, ~5 2 41

45 1 ISO

46 IV ISO9000 ISO9000,, ISO9000, ISO9000, ISO9000 ISO9001, ISO ISO

47 ISO9000 ISO9000 ISO9000, ISO9000 ISO ,,, 1., 2. 3., 4. 5., 44

48 ,

49 , / 4. ISO9000, ISO9000 ISO9000 ISO , 46

50 , Where, Who What 1 47

51 /

52 6-3 ISO ISO

53 ISO ISO9000 ISO9001 ISO9001 ISO

54 ISO ISO

55 ISO9000 ISO ISO ISO ISO

56 1 3 2 ISO ISO9001 ISO

57 ISO9001 ISO a 7.1 b " " ISO9001 ISO PDCA 54

58 ISO

59 ISO ISO ISO

60 ISO

61 58

62 59

63 ISO9001 ISO ISO ISO : ISO

64 QMS QMS 4.1. QMS QMS ISO

65 QMS / 62

66 / / ISO

67 64

68 65

69 ( ) 66

70 ( ) 67

71 68 ( ) ( )

. 1 EBM Evidence-Based Medicine JCAHO 2

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