1 2 : - - . . :

1 2 : - - . . : . !

3 -

1863 4 5

: : . 6 7

: )1 : )2 )3 : )4 )5 )6 .

) 7 8 9 . 9 .1 .2

.3 .4 .5 .6

.7 .8 .9 10 1 Identification Patient

...... . ...... . .

11 ( " " " " )-" )- . - . 12 : ( )

13 . :

/ : : ( / / ) 14 . ( ) (.

) 15 - / / : ( / / ) / .-- / / . - . 16

: . : ( ) DVT : 17

( : ( )- - - - - 18

: . 19 (

MS 30 ( ) 20 :

( )

( .

2 1 (

( )

22 : ( ) 2 3

Injection Safe -2 ( ) . )) needle stick24 :

- 1 ( ) - 2 / - 3 25

( ) 26

27 70

28 -3 Hygiene Hand

. : needle stick

29 8-7 : -1 . -2 . -3

. -4 ( 6) . -5 30 . . .

60-40 : 30-20: 31 5 .1 .2 / .3 .4 .5

32 Hand Rub . ( ) . .

. 33 ( 4 Safe ) - Surgery

34 . : :

. 35 : ( )...

. . : ( ) :

36 :

( ) Implant : ( ) ( ) : : 37

38 -5 : . hydrOXYzine : 39 hydrALAzine

: 40 .1 . .2 .3 .4 TALL MAN LETTERING

DOBUTamine ,DOPamine .5 / : 5-1 : ( ) 41 . 5-2 .

TO/VO RB)Telephone Order/Verbal Order Read (Back 5-3 24 5-4 : . 42 8R 43

. ( High )Risk ,KCL .

44 : " " 48

Kcl Double Check .

. . 45 ( ) .

. 46 . order () capital

47 48

7 1 8 2 9

3 10 4 11

5 12 6 : 48 : Communication During Patient )Hand (-Over

(Hand Off)Hand Over . Hand Off : .... 49 : HAND OFF . ( ) Hand Off .

SBAR . . ( ) . . . 50 SBAR SBAR .

( Situation -1(: : / ) ( :Background -2 ) / / / / / .... / / / 51

: ( Assessment -3 ) : ( /)V.S Mental / / / / / / (: Recommendation -4 ) " )- " )- " )- : 52

53 -8

. ( . : ( CVP( , LINE 54

.1 Hand Off .2 . . .3 . .4 ( : ) . .5 . .6 . .7 . .8

: 55 . 19: ( ) / / .

-2 56 57

. .

58 pending test result . / .

59 Panic Value .

. SBAR . () . 60 61

62 63 . ( ) . 64

65 2. : . 3. : .

( ) . 66 Active Failures -1 ( Human-Machine interface) Latent Errors -2

67 Active Error Latent Error -1 Scapelt Blunt Sharp End ( End Scapel ) -2 -3 ( ( ) ) -4 (

( ) ) ( ) -5 -6 ( ) 68 : :

69 -1 Sentinel Event )Misadventure( -2 No Harm Event -3 Near Miss 70 Important

71 72 : ...

73 " )- 74 : .

. . . 28 . . . . . . .. 75

: 76 2 46 . 20 6:45 ICU . (

) 77 . 2

78 ( 21) High Risk risk

9 3 34 8 Na/k . COPD . 11k:6.5( / ) Na:130 .

k:3.8 /Na: 138 . 79 80 -

81

/ / 82

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