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9 :45 A 425 ( ) /54 95/ A () A A 20:00 A B A B A B 21:07 6 X 21:11 A 39.0 SpO A 19:45 A C 21:14 A C A C 21: PHS TEL ( ) X 6

10 21: : A A A ()SpO2 ( A)99 ()() ()() ()() () () A () A A A 4 A A A A 23 A 21: :28 KN3 KN3B500mL 1 100mL 1 100mg 2 A 7

11 A 21:29 A C A C C C C A A TEL C 4 A 21:30 200mg 21:31 4 Y 1 21:34 6 Z 34 Z A B B A B A A B KN3 C () C C C B C 8

12 B C KN3 500mL C B KN3 500mL C B C 2 C B B 100mL1 100mg5mL2A div C B KN3 500mL 425 B B B B C 100mL 2A B C C BKN3 500mL 12 C B C B 21:40 Z B B15 20 B 100mL B :42 B B 9

13 B 21: Z 6 X 21:55 A B A B :10 A 25mL 2 22:13 A A B A 22:30 A KN3 500mL 23:50 A A A C C B C C C C B C B C C 10

14 C C A A A B C A B 23:55 PHS B 4 B PHS B C 23:57 B A B B C 7.0Fr D A 1A B C

15 :08 PHS 410 FiO2 1.0RR15 TV 500 PEEP8ACLS3 8A A 410 B A 250mL C 4 3A 3 () A 5 2A 10A 10A 0:55 B 1:05 A () C 2 1:45 () 4 A B C 3 12

16 CRP X-PCT

17 mL CT 14

18 1 2 m 34 A 15

19 23 5R(Right Patient Right Drug Right Dose Right Time Right Route)

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21 1 () 18

22 mL 19

23 A C C B ACLS ACLS 20

24 H H H H H H H H H H H H H H H H H H H H

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27 ERCP ERCP ERCP

28 3 ICU 1 ICU /

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30 ICU MRSA A B C

31 ICU

32 TPN

33 IT

34 JSA ID 1 31

35 CD

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38 % % 081 0% 2 35

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40 ACLS(Advanced Cardiovascular Life Support)

41 2 3 DVD DVD NST 1 ACLS MRM ICT

42 5 5R Right Patient Right Drug Right Dose Right Time Right Route 5R OJT(on the job training OJT 39

43 5R NST

44 ICU DPC 16 MRIDSA Ver

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47 RCARoot Cause Analysis

48 mg 45

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59 MEDI-Papyrus

60 ICU

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69 11 18 RFO

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73 NDP NDP Best Practice IT RCA RCA 3 70

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