Confidential Anesthesia Safety Report

为了麻醉管理的安全或减少麻醉事故，有必要收集麻醉事故，据报道，麻醉事故的发展是麻醉事故的30到50倍。本研究的目的是建立麻醉安全报告系统。在滨松大学医学院麻醉学系，我们建立了麻醉安全报告中心。为了保护麻醉医师举报麻醉事件的法律责任，我们采用了保密的麻醉事件报告制度。通过使用该系统，他们可以向我们的中心保密地报告麻醉事件。在这一阶段，静冈县的20多家医院符合我们的宗旨。麻醉病例总数为3.6万例/年。我们可以从这些医院得到50份报告。幸运的是，在没有让每一位麻醉医生都通报这一事件的情况下，还没有任何可能引发严重麻醉事故的报道。几乎所有的事故报告都有人为错误。由于回复报告的数量较少，我们无法在现阶段分析这些报告。然而，该系统仍在工作，它可以检查与新仪器有关的微小但可能引发严重事故的缺陷。

For safety of anesthesia management or for decrease anesthesia accidents, it is necessary to gather anesthesia incidents which, it is reported, developed from thirty to fifty times more than anesthesia accident. The purpose of this research was to make a anesthesia safety report system.In Department of Anesthesiology of Hamamatsu University School of Medicine, we established Anesthesia Safety Report Center. In order to protect the anesthetists who report anesthesia incidents from the legal affairs, we used confidential anesthesia incident report system. By using this system, they can report anesthesia incidents confidentially to our center. In this stage, more than 20 hospitals in Shizuoka prefecture were in accordance with our purpose. Anesthesia cases were 36,000/year in total. We could 50 reports from these hospitals. Fortunately, there were no reports that could evoke serious anesthesia accident without making every anesthesia doctors informed this incidents. Almost incident reports have something with human error. Because of low numbers of reply reports, we could not analyze these reports in this stage. However, this system is still working and it can check the even small but possible to evoke serious accidents defect concerning with new apparatus.