舒血宁注射液上市后临床安全性监测小结表（哈尔滨第一医院）

舒血宁注射液上市后临床安全性监测小结表

项目名称舒血宁注射液上市后临床安全性监测

项日来源“重大新药创制”国家科技重大专项。0.2009ZX09502-030)

伦理审批单位中国中医科学院中医临床基础医学研究所伦理委员会批准日期2012.9.18

国际注册号NCT01752916批准口期2012.12.19

监测单位名称

监测单位地址邮编：

监测单位属性口牵头单位口分中心监测模式口全院监测□病区/科室监测

监测单位负责人职务/职称

是否需要监测单位□否口是，

伦理委员会审批伦理委员会名称：批准日期年月日

合同监测病例数实际监测总病例数

末例患者观察结束日期

首例患者入组日期

年月日年月日

来源科室名称病例数不良事件不良反应描述

监测数据

死亡病例：口无口有_____例。

死亡原因说明：

死亡或严重不良反

应/事件发生情况

严重不良反应/事件：口无口有_____例，

说明：

本中心声格按照方案要求进行该品种监测，符合医学伦理学的准则，监测数据真实、

监测中心负责人对

数据真实性承诺完整、具有可溯源性。

监测中心负责人签名：日期：年月日

本临床监测全部过程按照监测方案实施，并得到很好的质量控制，完成情况良好。

单位审核意见

数据真实、完整、可靠。

单位盖章：日期：年月日

附表1主要参加监测人员名单

监测医院名称（盖章）：

姓名职称所在科室研究中分工签名

附表2舒血宁注射液上市后临床安全性监测清单

监测医院名称（盖章）：

患者姓名住院号

序号/姓名缩写性别年龄/病历号所在科室开始用药日期结束用药日期

1LHBIAC1739592015-01-252015-02-06

2TXJUAC1543332015-01-252015-01-27

3YXYIAC1330382014-10-272014-11-09

4LHLIAC1446542014-10-272014-11-03

5LYHAAC0627272014-10-272014-11-10

6LQCHAC1655212014-10-272014-10-31

7LLHUAC1660872014-10-272014-11-10

8WZJUAC1659692014-10-272014-1)-04

9LDXIAC1659982014-10-272014-11-03

10ATXIAC1660732014-10-272014-11-05

11WSJUAC0604692014-10-272014-11-11

12LDYIAC1660682014-10-272014-11-10

13MEB1AC1659812014-10-272014-11-07

14ZSYAAC0690912014-10-272014-11-07

15WXZHAC1659512014-10-272014-11-07

16YPXIAC1658012014-10-272014-11-05

17GYGUACI660172014-10-272014-11-04

18ZXMIACI660152014-10-272014-11-03

19GCHUAC0550272014-10-272014-11-04

20JFJUAC1659352014-10-262014-10-26

21YLHOAC1659342014-10-262014-11-11

22YHCHAC1658912014-10-252014-11-07

23HSROAC1658832014-10-252014-11-02

24GRXIAC1658792014-10-252014-11-05

25CSLIAC0836222014-10-252014-11-08

26PJLIAC1655632014-10-252014-10-27

27LYCOAC1657502014-10-242014-11-07

28CHJIAC1657672014-10-242014-11-04

29SYJIAC1658182()14-10-242014-11-05

30ZADAAC1015892014-10-242014-11-07

31WHSOAC1658162014-10-242014-10-30

32ZYHUAC1653242014-10-242014-10-29

33SOXIAC1403162014-10-242014-11-06

34YLJUAC0702942014-10-242014-10-30

35TLXIAC1658532014-10-242014-11-05

36WJFAAC1658462014-10-242014-11-02

37YXFAAC1658472014-10-242014-11-07

38CHYIAC1658432014-10-242014-11-07

39PLJIAC1658192014-10-242014-11-03

40LISEAC1151452014-10-242014-12-02

41WBHUAC0594372014-10-242014-11-04

42DQYIAC0892822014-10-242014-11-07

43JIQIAC1658302014-10-242014-11-02

44WSMIAC1652172014-10-242014-10-31

45SCHAAC1437782014-10-242014-10-31

46TYJIAC1653832014-10-242014-10-31

47JIJIAC1656342014-10-222014-11-05

48LWBIAC1656132014-10-222014-10-31

49SYDAAC1161652014-10-212014-10-31

50WYZHAC1518842014-10-212014-10-28

51CBFEAC1093072()14-10-212014-10-27

52YWFEAC1653972014-10-212014-11-02

53ZFLAAC1646932014-10-212014-10-27

54MYRUAC0908292014-10-212014-10-31

55LI.IlJAC1654192014-10-212014-10-23

56WDJIAC1643362014-10-212014-11-04

57ZDZHAC1434262014-10-212014-10-27

58ZHXIAC1654482014-10-212014-11-02

59HJSHAC1654042014-10-212014-11-02

60WHROAC1654012014-10-212014-10-30

61YYRUAC1503082014-10-212014-11-05

62XUYIAC1232992014-10-212014-11-03

63YSHUAC1656032014-10-212014-10-25

64SSSHAC0959052014-10-212014-11-07

65TYQIAC1655312014-10-212014-11-03

66CYFEAC1654322014-10-212014-11-05

67KQHUAC1654052014-10-232014-11-03

68HDLIAC1353752014-10-232014-10-31

69WSZHAC0680202014-10-232014-11-04

70LYQUAC1657362014-10-232014-11-03

71YUJIAC1650062014-10-232014-10-31

72WAXIAC0994252014-10-232014-10-31

73LIDEAC1657912()14-10-232014-11-05

74WXYUAC1110762014-10-232014-11-02

75GWFAAC1657802014-10-232014-10-31

76WXYUAC1656042014-10-232014-11-01

77GOLIAC1534232014-10-232014-11-06

78YXZHAC1655322014-10-232014-11-03

79SMXIAC1O17O62014-10-232014-11-06

80BSQIAC0995922014-10-232014-10-29

81JLHUAC1656622014-10-232014-10-27

82SYFEAC1220542014-10-232014-11-05

83TYZHAC0557752014-10-232014-11-01

84LXHOAC1657092014-10-222014-10-27

85HJYOAC0913942014-10-222014-11-03

86LRTIAC1656012014-10-222014-10-27

87YUJIAC0797832014-10-222014-11-04

88LIBIAC1656322014-10-222014-11-03

89FUJIAC1655972014-10-222014-10-22

90WZQIAC1657222014-10-222014-10-31

91MDANAC1657152014-10-222014-10-31

92GFQIAC167I742014-11-102014-11-19

93TSXIAC1680542014-11-182014-11-21

94LXQUAC1680692014-11-182014-11-27

95LFJUAC1234882014-11-182014-12-02

96SFLAAC1681402()14-11-182014-12-0i

97FXDOAC1680302014-11-182014-11-23

98LGPIAC0946752014-11-182014-12-02

99ZI.MIAC1680812014-11-182014-11-28

100ZSFEAC1679082014-11-182014-11-27

101WDLOAC0573482()14-11-172014-11-22

102WXJUAC1679642()14-11-172014-12-04

103ZFROAC1679612014-11-172014-11-28

104CRLIAC0753912014-11-212014-11-23

105LXFAAC1683162014-11-212014-12-04

106SYHUAC1684722014-11-212014-11-27

107JQLIAC0810582014-11-212014-12-12

108NYFEAC1678622014-11-212014-11-25

109WUUAC1419802014-11-212014-12-01

11()ZHJUAC13O1812014-11-212014-11-28

111WSQIAC1221832()14-11-212014-12-03

112HQFUAC1683812014-11-212014-11-27

113XGWEAC1684882014-11-222014-11-25

114LJXIAC0937712014-10-222014-11-05

115ZJROAC0857652014-10-222014-10-27

116LYQIAC0687932014-10-222014-10-22

117WQJUAC1655702()14-10-222014-10-31

118LLLIAC1656922014-10-222014-10-26

119ZYFEAC1673842014-11-112014-11-21

120SXHUAC0615942014-11-112014-11-15

121SS7.HAC1674532014-11-112014-11-18

122LXZHAC1674752014-11-112014-11-16

123WZQIAC0848152()14-11-112014-11-24

124SHRUAC1673092014-U-li2014-11-25

125WBQIAC1673142014-11-112014-11-25

126LJSHAC0889942014-11-102014-11-14

127YXJUAC0980772014-11-102014-11-19

128JSZHAC1002472014-11-102014-11-11

129MYBOAC1673422014-11-102014-11-23

130ZSXIAC1673692014-11-102014-11-24

131WYHUAC1063552014-11-102014-11-26

132H/XMIAC1673722014-11-102014-11-11

133LXYAAC1251582()14-11-102014-11-25

134LZQIAC1672282014-11-102014-11-18

135WYSHAC06II642014-11-102014-11-26

136BYJIAC1671642014-11-092014-11-26

137WMYUAC0571842014-11-082014-11-21

138CJBAACO57OO72014-11-042014-11-07

139SGYIAC1672082014-11-102014-11-23

140MCLIAC1671852014-11-102014-11-22

I4iHLHOAC1672462014-11-102014-11-23

142TLBIAC167I872014-11-102014-11-20

143XIHAC0916892014-11-222014-12-04

144WZYUAC1684792014-11-222014-11-27

145CABIAC1346582()14-11-212014-11-27

146GSTAAC1683142014-11-212014-12-02

147FCMEAC1680362014-11-182014-12-01

148WJTAAC0875222014-11-282014-11-29

149GAQIAC1682282014-11-202014-11-21

15()YSQIAC0843762014-11-202014-12-02

151JXSHAC1158002014-11-202014-12-04

152SYYIAC0925372014-11-202014-11-28

153MYQUAC0987262014-11-202014-12-02

154ZQFEAC1684272014-11-212014-11-27

155DXSHAC0932752()14-11-212014-12-02

156LYFUAC1682662014-11-212014-11-21

157ZXZHAC1683502014-11-202014-12-04

158CZLIAC1682102014-11-202014-12-01

159CSZHAC1683022014-11-202014-12-04

160HXWEAC1681872014-11-202014-12-03

161YLCHAC1683272014-11-202014-12-04

162ZJWEAC1101342014-11-192014-11-27

163NFLAAC1678922014-11-192014-11-28

164TWBAAC0571902014-11-202014-11-24

165CFYIAC1341802014-11-192014-12-01

166LHJIAC1681702014-11-192014-11-28

167LXYUAC1680952()14-11-192014-11-19

168CFROAC1681462014-11-192014-12-04

169LXJUAC1682712014-11-192014-11-27

170GSZHAC1682182014-11-192014-12-02

171WYXIAC1683122014-11-202014-12-01

172LXYIAC1682882014-11-202014-11-26

173SFYIAC1683492014-11-202014-12-02

174CDSHAC1683052014-11-202014-11-25

175YGXIAC1681762014-11-192014-11-27

176CPKUAC1372952014-11-192014-12-02

177LZYUAC0961312014-11-182014-11-30

178ZBFEAC1115202014-11-182014-12-10

179QUJIAC0798302014-11-182014-11-24

180ZHJIAC0607992014-11-192014-12-02

181WYJIAC1681792014-11-192014-12-02

182LIXIAC1681912014-11-192014-11-27

183HSERAC1681802014-11-192014-12-03

184JXYIAC0554342014-10-312014-11-11

185ZSQIAC1662582014-10-302014-11-13

186PLZHAC1662632014-10-302014-11-08

1X7WXHOAC1663932014-10-302014-11-10

188WXHUAC1552542014-10-302014-11-05

189ZYJIAC1662662014-10-302014-11-09

190WJYOAC0924022014-10-302014-11-10

191MRYIAC1655872014-10-302014-10-30

192PJZHAC1663602014-10-302014-11-12

193TXZHAC1663282014-10-302014-11-10

194WGQIAC1662702014-10-302014-12-11

195GZHAAC1663642014-10-302014-11-10

196LQXIAC1663582014-10-302014-11-10

197YWPIAC1662732014-10-302014-11-10

198ZYLIAC0819482014-10-292014-11-09

199LZLOAC0723942014-10-292014-11-05

200GALUAC1661252014-10-292014-11-10

201YZFEAC1658882014-10-292014-11-11

202SFQIAC1659362014-10-292014-11-11

203YBXIAC1455572014-10-292014-11-03

204CSPIAC1662952014-10-292014-11-17

205LSQIAC0687992()14-10-292014-11-11

206ZDLIAC1661322()14-11-012014-11-07

207MCAIAC1664822014-11-012014-11-15

208XYCHAC1664912014-11-012014-11-10

209YAMIAC128I122014-11-012014-11-11

210WLXIAC1147732014-11-012014-11-09

AC125374

211HYZH2014-11-012014-11-20

AC166485

212HMLA2014-11-012014-11-13

AC128709

213LXLI2014-11-012014-11-06

AC133995

214ZSHU2014-11-012014-11-04

ACO6O487

215LFRO2014-10-312014-11-20

AC086423

216GYPI2014-10-312014-11-11

AC142546

217YQWE2014-10-312014-11-13

AC166316

218YYZH2014-10-312014-11-11

AC166471

219LBHA2014-10-312014-11-07

AC092845

220LXLI2014-10-312014-11-11

221HGLIAC1664642014-10-312014-11-11

222LICHAC1663412014-10-312014-11-04

223DYZHAC1664192014-10-312014-11-13

224ZJROAC1664492014-10-312014-11-09

225CHRUAC1022812014-10-312014-11-11

226GLMIAC1664382014-10-312014-11-14

227WYMIAC1665372014-11-022014-11-18

228ZSJUAC0607982014-11-022014-11-15

229YXQIAC0803792014-11-022014-11-11

230ZZWEAC1665302014-11-022014-11-10

231IXROAC1665202014-11-022014-11-11

232Y/XMEAC1664632014-11-022014-1)-11

233LWJI