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2. . . . ( ) . . . 3. 4. 5. (Betsy Lehman) 37 Dana Farber 1mg 4 endoxan 4mg 4 6. (Willie King) 51 7. (Ben Kolb) 7 lidocaine(epinephrine)( ) 8. IOM(Institute of Medicine) IOM 1999 ToErrisHuman BuildingasaferHealthsystem ) 44000 ~98000 9. 20 WHO 1999~2005 2003 21 10. (Patient Safety) . . 11. (PatientSafety Management) 12. . . . . . . . 13. . . . RCA(rootcause analysis) . HFMEA HealthcareFailureMode&EffectAnalysis) . . 14. . . (informedconsent) . . . . . 15. 16. 17. . . . . ( 18. . ( ) 19. . . . . . 20.