In January, when a male patient in his 80s underwent dialysis at a hospital in Kyoto City, a large amount of blood spilled out and he became unconscious and died afterwards, according to an interview with the people concerned. I understand.

The hospital apologized to the bereaved family, probably because some of the dialysis machines were loose.

According to the people concerned, when a male patient in his 80s underwent dialysis at "Rakuwakai Touji Minami Hospital" in Minami-ku, Kyoto City in January, his condition suddenly changed and he became unconscious. Died.



According to the hospital's investigation, when the blood was returned to the body, it entered another tube and a large amount of blood was spilled, so it seems that the nurse in charge started dialysis with the equipment to prevent the spill loose. It turns out that it can be done.



When starting dialysis, an alarm indicating an abnormality sounded, but the nurse turned off the alarm and continued working, and then two alarms prompting for blood pressure measurement, but other staff members also sounded the patient's complexion. It means that it was judged that there was no abnormality just by checking such things.



The hospital admitted that it was a medical accident and explained the circumstances to the bereaved family and apologized, but did not disclose the accident.



Rakuwakai Touji Minami Hospital said in an interview with NHK, "I will not comment."

Expert "In a serious accident because the alarm cannot be dealt with"

Regarding this accident, Toshio Shinoda, Vice Chairman of the Japan Dialysis Medical Association, said, "Even though the alarm is sounding, ignoring it and proceeding to the next process is absolutely not possible for safety management. I wasn't able to respond correctly to the alarms, such as listening to the symptoms and measuring the blood pressure, which may have resulted in a serious accident. "



On top of that, regarding recurrence prevention measures, "If there is a defect in the blood circuit, it is necessary to ignore the alarm and improve it so that the work can not be continued. Also, those who are involved in dialysis treatment are treated that are life-threatening for the patient. It is necessary to always keep in mind what you are doing. "

Past dialysis accidents

Regarding dialysis, there have been accidents in which patients die due to work mistakes by medical staff.



Of these, at Kyoto University Hospital, in 2011, a male patient in his 50s died due to dialysis with incorrect parts attached, and two doctors and one nurse sent documents on suspicion of accidental fatalities in business. it was done.

The three were subsequently suspended from prosecution.



In addition, in the 2013 survey of medical accidents during dialysis conducted by the Japan Dialysis Medical Association, more than 1,700 hospitals and clinics nationwide reported 519 accidents annually.



Of the 422 cases in which the details of the accident can be understood,


▽ accidents in

which the

needle comes off are the most frequent in 167 cases,


▽ accidents in which falls or falls are 49 cases, and


▽

accidents in which the

blood circuit connection is disconnected are 22 cases. ..



On the other hand, according to the Japan Dialysis Medical Association, the safety devices of dialysis machines have been improved recently, and the safety awareness of medical staff has improved, so that serious accidents due to human error have rarely occurred.