インシデントの被害度分布形状パターンの活用法に関する提案(機械要素,潤滑,工作,生産管理など)

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A necessity of an incident-reporting system has been conceived, but some problems for an effectiveness of the system can be still remained. The first is about a difference between a number reported and that practically occurred. Some researches indicate the difference can be affected by a management styles, such as a productivity and safety of a work place. This gap is attributed by a substantial limit of the incident reports; that is, reporting is voluntary by a.reporter and a manager has much difficulty for judgment whether the change in a number of reports owes not to a lack of a reporting effort but to an effect of measures. The second is evaluating difficulty for an effectiveness of the reporting system. A change in a number of reports, which is an only visible value for a manager of an organization, is not necessarily reflected by an actual change in an error frequency. Then it is difficult to evaluate the effectiveness only with the number of the reports. In this paper, we propose a quantitative shape indicator of a damage distribution of incident reports to evaluate this effectiveness. We observed the relationship between the pattern indicator we proposed and a number of a fatal incident reports in one Japanese hospital. The result showed a positive correlation in the two factors, as we predicted. This indicator can be reflected by an enthusiasm for reporting or an effectiveness of safety measures based on an experimental relation to the frequency of fatal incidents. Consequently, the concept we proposed is effective to consider the effectiveness of a safety management activity using an incident report for not only in a patient safety, but also in an engineering safety.
一般社団法人日本機械学会の論文
2008-04-25

インシデントの被害度分布形状パターンの活用法に関する提案(機械要素,潤滑,工作,生産管理など)

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