《市民病院医療事故多発》「外部検証が必要」指摘スルー
2024年08月31日
赤穂市民病院の脳神経外科手術で2019年から20年にかけて少なくとも8件発生した医療事故をめぐり、院内の医療安全推進室がそのうち6件で外部専門家による検証の必要性を指摘していたことが病院の内部文書でわかった。実際には外部検証は3件しか行われず、同病院の医療安全の機能不全が改めて明らかになったと言える。
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)
赤穂民報は「医療安全推進室検討分」との表記があるA4判15枚の文書を入手。8件の医療事故それぞれについて、発生した経緯や今後の対応などを脳神経外科がまとめた報告書をベースに、同室が疑問点や矛盾点を加筆したものとみられる。
例えば、脳梗塞のカテーテル手術でワイヤーが血管を突き破って手術中止となり、脳死状態となった80代女性患者(当時)の症例では、医師らが「ワイヤー穿孔の発生がやむを得ない当然の結果であり、そもそもこれを事故として取り扱うこと自体がナンセンス」と手術の正当性を主張しているのに対し、同室が「穿孔となり、脳ヘルニアから脳死に至ったことが当然の結果と言えるのか?」と疑問視した上で、「外部専門家による画像の確認および判断が必要」と意見を付している。
外部検証の必要性を指摘した記述は8件中6件で見られるが、病院のこれまでの説明では、実際に外部専門医に検証を依頼したのは3件。あとの3件は外部検証を行わないまま医療過誤(ミス)はなかったと結論付けている。
また、ドリルで頸髄を損傷して首から下が不随になった70代女性患者(当時)の症例に関する文書では、報告書に記載されている医療事故の発生状況と患者側への説明が一致していない点に着目し、「医療事故と認識していたのにも関わらず、患者(家族)への説明および、医療安全推進室への報告をしなかったのは事故を隠蔽したと言う事か?」と隠蔽を疑う記述もあるなど、8件すべてで何らかの疑問や矛盾が指摘されている。
病院がこれまでに開示した資料には、これらの指摘について検証した形跡は見当たらない。病院は医療安全推進室の指摘をどのように取り扱ったのか。また、外部検証が必要とした同室の判断が覆ったのはなぜなのか。病院は赤穂民報の取材に「係争中のため、お答えは差し控えます」と返答。一連の医療事故問題は最初の発生から丸5年が経っても、いまだ全容が解明されていない。
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掲載紙面(PDF):
2024年8月31日号(2565号) 1面 (6,150,246byte)
(PDFファイルを閲覧するにはこちらからAdobe Readerを入手してください。)
外部検証の必要性を指摘している赤穂市民病院の文書=医師名の部分は加工しています
赤穂民報は「医療安全推進室検討分」との表記があるA4判15枚の文書を入手。8件の医療事故それぞれについて、発生した経緯や今後の対応などを脳神経外科がまとめた報告書をベースに、同室が疑問点や矛盾点を加筆したものとみられる。
例えば、脳梗塞のカテーテル手術でワイヤーが血管を突き破って手術中止となり、脳死状態となった80代女性患者(当時)の症例では、医師らが「ワイヤー穿孔の発生がやむを得ない当然の結果であり、そもそもこれを事故として取り扱うこと自体がナンセンス」と手術の正当性を主張しているのに対し、同室が「穿孔となり、脳ヘルニアから脳死に至ったことが当然の結果と言えるのか?」と疑問視した上で、「外部専門家による画像の確認および判断が必要」と意見を付している。
外部検証の必要性を指摘した記述は8件中6件で見られるが、病院のこれまでの説明では、実際に外部専門医に検証を依頼したのは3件。あとの3件は外部検証を行わないまま医療過誤(ミス)はなかったと結論付けている。
また、ドリルで頸髄を損傷して首から下が不随になった70代女性患者(当時)の症例に関する文書では、報告書に記載されている医療事故の発生状況と患者側への説明が一致していない点に着目し、「医療事故と認識していたのにも関わらず、患者(家族)への説明および、医療安全推進室への報告をしなかったのは事故を隠蔽したと言う事か?」と隠蔽を疑う記述もあるなど、8件すべてで何らかの疑問や矛盾が指摘されている。
病院がこれまでに開示した資料には、これらの指摘について検証した形跡は見当たらない。病院は医療安全推進室の指摘をどのように取り扱ったのか。また、外部検証が必要とした同室の判断が覆ったのはなぜなのか。病院は赤穂民報の取材に「係争中のため、お答えは差し控えます」と返答。一連の医療事故問題は最初の発生から丸5年が経っても、いまだ全容が解明されていない。
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掲載紙面(PDF):
2024年8月31日号(2565号) 1面 (6,150,246byte)
(PDFファイルを閲覧するにはこちらからAdobe Readerを入手してください。)
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