著者

山本 鋭二郎 岡 耕平

出版者

公益社団法人 日本放射線技術学会

雑誌

日本放射線技術学会雑誌 (ISSN:03694305)

巻号頁・発行日

vol.75, no.11, pp.1249-1259, 2019 (Released:2019-11-20)

参考文献数

15

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In recent years, workload has increased with higher precision of radiotherapy. Although both efficiency and thoroughness of treatment are crucial, in such conditions, human error is easy to occur. In this study, five incident cases that occurred in four facilities were studied and analyzed from the viewpoint of human factors that contribute to errors using variation tree analysis. We also analyzed resilience (the ability to return to one’s original state even if the system deviates from a stable state), which has attracted attention in recent safety research. There were potential factors represented by patient factors in all cases. These factors caused deviations from standard operations, and incidents occurred due to unfamiliar situations and operations. Furthermore, in four of the five cases, the cause of the incident was a resilience action or judgment that was deemed to have required “some sort of ingenuity or adjustment.” It was found that human error occurred due to multiple simultaneous occurrences of potential factors, i.e., patient and human factors such as high workload, impatience, and work interruptions. A reduction in human errors can be achieved by avoiding time pressure and multitasking, creating work environment and working conditions that make resilience work well, revising ambiguous rules and procedures, and promoting standardized working methods.

著者

片岡 耕平

出版者

校倉書房

雑誌

歴史評論 (ISSN:03868907)

巻号頁・発行日

no.816, pp.31-42, 2018-04

著者

渡辺 浩一 來山 政明 太田 一 松村 敏博 徳永 将人 新 直也 川岡 耕平 松村 さとみ 吉田 弘司 谷川 宮次

出版者

比治山大学

雑誌

比治山大学紀要

巻号頁・発行日

no.24, pp.173-179, 2018

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The Ministry of Education, Culture, Sports, Science and Technology has urged each universityto promote efforts of cooperative work between academic staff and non-academic staff. The IR(Institutional Research) committee of our university is an organization with the cooperative work,and each member carries out activities and cooperative work making full use of their expertise. At the end of FY2016, we conducted mutual evaluation on IR with a university in the Tohoku region and made evaluations including staff expertise. In addition, as for the activity in FY2017, each staff is carrying out analyses and other activities making full use of the expertise of their department, as well as the previous year, and we are promoting further approach including the policy proposals.