21 8 20
70 1
1 2 1 1 20 12 22 16201835 2 21 1 21 15001910 3 21 2 23 15001750 4 21 3 23 15002030 5 21 4 27 15102010 6 21 6 15 15002110 7 21 7 27 15001910 2 3 3 21 3 21 4 2
4 1 2 1 2 312 4 3 1 2 3 4 2 3 4 5 6 1 4 3
5 1 2 3 4 5 6 7 20 12 3 4
1 70 3 7 3 20 10 25 38.9 11 17 39.4 8 4 20 4 12 4 11 17 5 9 14 3 17 4 17 4 3 2 3 19 10 14 4 14 4 3 17 4 15 4 15 4 2 6 17 10 53 5 53 4 5 4 5
2 20 11 17 19:45 A 425 ( ) 37.8 130/54 95/ A () A A 20:00 A B A B A B 21:07 6 X 21:11 A 39.0 SpO2 39.4 1 A 19:45 A C 21:14 A C A 39.4 19 C 21:16 6 4 PHS TEL ( )4 39.4 X 6
21:18 6 10 26 4 21:20 4 425 425 A 37.8 9 4 A A ()SpO2 ( A)99 ()() ()() ()() () () A () A A A 4 A 425 425 A 37.8 9 4 A A 23 A 21:26 4 21:28 KN3 KN3B500mL 1 100mL 1 100mg 2 A 7
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
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 B15 20 21:42 B B 9
B 21:46 4 6 6 Z 6 X 21:55 A B A B 15 20 22:10 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
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 3 2 11
20 11 18 0:08 PHS 410 FiO2 1.0RR15 TV 500 PEEP8ACLS3 8A A 410 B 410 410 1A 250mL 3 3 6 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
CRP X-PCT 1 39.4 10 25 7 13
70 3 100mL CT 14
1 2 m 34 A 15
23 5R(Right Patient Right Drug Right Dose Right Time Right Route) 15 20 16
3 3 3 17
1 () 18
1 3 5 21 100mL 19
11 17 2350 A C 4 2355 C B 2357 4 2 ACLS ACLS 20
1 61 37 56 32 56 31 51 27 51 27 41 14 12 37 12 39 8 35 9 35 8 33 8 32 4 60 36 5 8 35 10 5 6 10 H11 7 11 492 0 4 H12 6 13 2 11 2 3 4 H13 9 14 1 11 5 3 4 H14 4 13 1 10 11 2 4 H14 7 14 1 11 11 2 4 H15 4 13 0 10 15 1 4 H16 7 13 0 12 15 4 3 H17 4 13 0 11 15 4 3 H18 10 13 0 12 15 4 3 H18 12 14 0 13 15 4 4 H18 1 13 0 12 15 4 3 H19 2 14 0 12 15 4 3 H19 4 13 0 11 15 4 3 H19 7 12 0 10 15 0 2 H19 12 13 1 10 15 1 2 H20 1 13 1 10 15 1 2 H20 4 14 1 12 15 2 2 H20 7 13 1 11 15 2 2 H20 11 14 1 11 15 3 4 H20 12 13 19 15 3 3 10 58 13 4 21
1 16 3 31 16 1617 17 3 18 4 18 11 3 20 40 1 12 30 50 20 3 50 60 51 21 3 2 2 2 18 12 13 19 3 1 1 1 20 3 22
11 1 14 100 13 11 3 9 16 34 19 2 7 30 8 50 8 30 8 50 1320 14 15 2 1 1 30 12 3 10 20 1 15 20 20 30 21 8 50 1 1.5 23
10 1 15 12 10 20 13 13 2 1 30 45 15 15 30 1 18 18 20 1 20 7 10 11 12 13 2 ERCP ERCP 1 1 19 ERCP 17 18 21 21 30 5 10 12 13 2 1 17 21 30 9 8 40 15 30 1 2 1 20 20 9 30 1 30 24
3 ICU 1 ICU 5 46 1 15 12 20 56 0 6 32 17 20 21 2 36 3 20 4 10 130 122 10 18.9 1 1.5 2 4190 68 1 19.031.9 24.6 4 110 200 20 60 / 11 9 2 2 1 56 25
3 1 3 1 12 1 3 5 6 5 3 1 20 6 11 17 80 9 11 17 14 2 15 2 15 16 2 26
11 17 19 1 14 4 5 3 11 17 22 7 1 293 3 13 34 104 69 55 17 38.1 15.1 185 326 4 26 5 25 6 27 429 5 26 6 26 ICU25 17 55 3 20 10 17.3 11 13.7 12 16.8 51 14 4 9 1 97.8 20 10 29 3 25 13 4 8 3 83017151415 16000454 3 20 7 4 45 MRSA 5 1 22 A402411 8 B412420 24 5 C421430 54 3 401 4 1 0159003 20 10 10.7 11 10.7 12 14.0 27
20 11 1 257.5 563.3 30 8 57 293 19 6 1 7 1 4 51 29 4 12 18 12 14 18 12 17 18 12 1715 830 90018001800 900 2 11 5 2 18 4 3 6 3 1 1 3 17 ICU 5 3 36 3 2 18 12 1920 17 83.8 16.2 23 23 60 28
12 1 13 TPN 18 12 24 12 1 2 2 1 18301715 1 1715 1230 2 18301230 1 1 2 152 58 94 85.1 36.7 44.4 4 7 16 2000 830 20 830 830 45 1230 1715 1230 45 1 23 1 29
1 15 15 1 2 16 7 18 2 IT 1 17 18 30
JSA 1 19 20 7 20 9 4 ID 1 31
2 100 2 CD 23 3 17 11 9 82 18 10 10 100 19 45 4 8 32
20 7 19 9 47 2 1 3 13 4 35 1 4 18 14 2 15 13 16 10 17 10 18 0 19 12 20 14 14 77 15 87 16 127 17 206 18 258 19 327 20 476 19 45 20 63 2 2 20 4 9 11 17 21 19 3 33
463 155 28 27 19 5 1 2 3 2 4 1 34
5 6 7 8 9 18 19 16 17 18 19 20 13 14 10 9 7 19 20 21 4 66 6% 7 130 5.4% 081 0% 2 35
1 1 2 2 3 4 36
1 2 5 1 ACLS(Advanced Cardiovascular Life Support) 2 6 20 5 4 37
2 3 DVD DVD NST 1 ACLS1 2 20 3 MRM ICT 9 1 1 30 1 38
5 5R Right Patient Right Drug Right Dose Right Time Right Route 5R 3 10 24 2 15 16 16 19 20 6 19 OJT(on the job training 19 6 68 1 15 OJT 39
5R 3 1 1 1 1 1 1 1 1 2 2 6 2 12 NST 1 2 1 52 1 301 6 307 50 14 12 25 40
15 2 17 3 8 12 14 15 10 1 5 16 6 1 ICU DPC 16 MRIDSA 3 18 15 1 19 6 Ver.5 4 58 10 2 16 41
14 17 5 18 12 13 19 4 11 7 10 20 4 12 20 7 11 11 1 110 13 11 21 4 8 18 3 5 4 19 9 3 8060 12 3 20 4 1 5 15 3040 16 2 11 45 39.5 10 20.4 19 16.5 2 1 2 23 3 26 11.6 17 82.3 19 14 149 22 208 19 42
9 9 1 15 4 3 6 3 20 16 20 6 26 43
RCARoot Cause Analysis 9 1 3 3 14 3 14 3 3 3 3 14 7 8 44
2 3 3 3 18 3 1 100mg 45
3 18 12 4 46
14 3 2 2 5 34 47
34 2 48
ICT NST 6 20 4 20 4 49
14 2 20 4 9 11 7 20 4 3 1 50
36 80 8 19 1 0 19 1 18 0 1 19 327 20 476 1 0 87 2.7 1.8 0.8 2.5 1.8 3.4 20 16 3 16 2 19 3 51
0 1 20 11 21 7 8 21 8 21 2 21 2 3 21 1 21 4 20 11 21 4 52
21 2 21 4 21 4 2 21 6 21 7 21 7 100 100 L 20 100 100L 20 3 21 1 21 4 53
4 6 7 3 11 21 1 5 21 7 3 7 2 11 21 7 21 5 5 54
21 4 3 / 7 21 6 21 21 7 6 21 4 7 16 55
16 1 2 3 18 1 2 3 21 1 1 4 5 18 5 3 4 3 1 2 1 16 19 3 5 19 2 18 12 20 11 21 2 3 1 21 4 2 21 3 2 20 9 1 21 3 1 3 1 1 21 4 18 60 65 18 2 18 4 20 10 18 7 18 10 18 7 19 6 18 19 11 21 5 17 12 MEDI-Papyrus 21 6 3 17 3 17 4 56
18 12 19 2 2 24 18 12 3 19 10 19 10 3 ICU 19 11 19 12 16 18 9 20 8 19 9 20 1 20 6 20 5 3 1 21 6 2 57
21 7 9 21 8 8 21 21 4 5 6 1 0 21 58
9 20 12 3 11 18 11 18 1 11 59
1 2 10 26 10 29 11 4 12 11 6 1 2 1 1 2 11 10 12 11 12 11 13 11 17 60
1 45 2 1 11 18 1 45 11 19 21 11 20 11 21 11 25 11 27 12 3 7 12 8 12 22 1 12 28 3 9 1 17 1 21 2 2 18 61
2 23 3 3 20 3 23 4 4 27 5 6 15 6 727 7 2 1 19 18 4 62
2 2003 2008 63
11 20 11 26 3 18 19 70 11 17 9 39.4 3 1 15 20 1 20 223023 45 2 1 45 64
18 19 6 19 9 18 19 2 65
11 18 RFO 11 19 11 28 11 19 9 3 20 20 66
11 21 18 19 70 11 17 9 39.4 3 1 15 20 1 20 23 45 2 1 45 67
18 19 6 19 9 18 19 2 20 11 21 20 11 25 20 11 25 68
3 3 12 12 3 7 50 RCA 3 69
NDP NDP Best Practice IT RCA RCA 3 70
19 0 0 20 6 52 PDCA 71
72
3 7 11 18 73
74
75
76
77
78
79
80
81
82
83
84
85
86