• Quality Improvement in Health Care
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• v.22 no.1
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• pp.41-57
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• 2016

Objectives: This study aimed to investigate how many healthcare professionals experienced near misses, what types of near misses occurred most often, and healthcare professionals' opinions about near misses at one university hospital in Korea. Methods: The authors developed a questionnaire including 26 core types of near misses and 4 questions about preventability and reporting barriers. The survey was conducted from Oct. 31st to Nov. 18th 2011, about 3 weeks, using a self-administrated questionnaire that was administered to 697 healthcare professionals (registered nurses, pharmacists, technicians, and nurses aides) who worked at a university hospital. Medical doctors and employees working in the department of administration were excluded. Results: About half of hospital workers experienced at least one or more near misses during the past one year. The drug dispensing process was the most common subcategory of near misses. Among the 26 items, patient falls was highest. Over 95% of respondents reported that the near miss they experienced was preventable. Also, more than half of respondents did not report the near miss and the main reason for omission was fear of blame. Conclusion: Regarding patient safety issues, a near miss is a very significant factor because it can be a potential adverse event. Therefore, we should grasp the size of the problem through tracking and analyzing near misses and should make an effort to reduce them. To do so, we should check whether our reporting system is well designed and functioning.

• Journal of the Korean Society of Safety
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• v.37 no.2
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• pp.28-34
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• 2022

This study analyzes the impact that accidents and near misses have on clients' and contractors' awareness of safety culture. Due to the unique characteristic of employment structure in Korea, the occurrence of accidents differs by company size, which has relevant implications for the establishment of safety culture. Attention has been drawn to the importance of the management of accidents and near misses, with safety awareness acting as a core factor. A positive effect on the prevention of accidents could be achieved by noting the difference in safety awareness between clients and contractors and suggesting an associated suitable safety management system. In support of this study, a survey was distributed to workers in the automobile manufacturing industry (May-August 2020), and data from a total of 574 workers was collected and analyzed, including 399 clients' worksers and 175 contractors' workers. The questionnaire addressed participants' experiences of accidents and near misses as well as 50 items from the Nordic Occupational Safety Climate Questionnaire. Analysis of the responses was conducted using the methods of frequency analysis, Fisher's exact test, t-test, correlation analysis, and regression analysis. The results demonstrated that clients had more experiences with accidents and near misses compared to contractors. Additional differences between clients and contractors were noted in terms of the safety culture factors of learning, communication, and trust. A correlation was observed between the experience of accidents and safety justice management: for clients and contractors who experienced accidents, safety justice management was 9.4 times higher. Furthermore, clients' and contractors' awareness of employees' commitment to safety was determined to be 28.5 times higher in those who had experienced near misses This study concludes that, in order to improve accident prevention through the management of accidents and near misses, clients must focus on overseeing safety justice management and aspects of safety culture factors, while contractors must focus efforts on managing employees' commitment to safety. In further applications, this study could provide baseline data for health and safety activities in terms of the safety culture of clients and contractors. Further study on the establishment of safety culture as related to employment structure is proposed for future research.

• Journal of the Korean Society of Safety
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• v.38 no.4
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• pp.54-59
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• 2023

The relationship between near misses and major accidents can be confirmed using the ratios proposed by Heinrich and Bird. Systematic reviews of previous national and international studies did not reveal the assessment process used in near-miss management systems. In this study, a model was developed for assessing near misses and major factors were derived through case application. By reviewing national and international literature, 14 factors were selected for each dimension of the P2T (people, procedure, technology) model. To identify the causal relationship between accidents and these factors, a near-miss assessment model was developed using a Bayesian network. In addition, a sensitivity analysis was conducted to derive the major factors. To verify the validity of the model, near-miss data obtained from the ethylene production process were applied. As a result, "PE2 (education)," "PR1 (procedure)," and "TE1 (equipment and facility not installed)" were derived as the major factors causing near misses in this process. If actual workplace data are applied to the near-miss assessment model developed in this study, results that are unique to the workplace can be confirmed. In addition, scientific safety management is possible only when priority is given through sensitivity analysis.

• Korean Journal of Construction Engineering and Management
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• v.20 no.4
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• pp.69-76
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• 2019

This paper presents a method that identifies the unsafe behaviors at the level of near-misses using image analysis. The method establishes potential collision hazardous area in earthmoving operation. It is implemented using a game engine to reproduce the dangerous events that have been accepted as major difficulty in utilizing computer vision technology to support construction safety management. The method keeps realistically track of the ever-changing hazardous area by reflecting the volatile field conditions. The method opens a way to distinguish unsafe conditions and unsafe behaviors that have been overlooked in previous studies, and reflects the causal relationship which causes an accident. The case study demonstrate how to identify the unsafe behavior of a worker exposed to an unsafe area created by dump trucks at the level of near-misses and to determine the hazardous areas.

• The Korean Journal of Nuclear Medicine Technology
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• v.14 no.2
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• pp.138-144
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• 2010

Purpose: Despite the rapidly changing healthcare environment, healthcare organizations have recognized the importance of patient safety management. But patient safety management has the problem of the lack of participation of members due to the process of focusing on the follow-up service and punishment. The department of nuclear medicine in Uijeongbu St. Mary's Hospital started this research to reduce the near miss and prevent patient safety accidents by both initiating the participatory near-miss-proof activities as an advance management and constructing a system without disadvantages of reporting. In addition, this research aims to establish a differentiated patient safety management system in the department of nuclear medicine. Materials and Methods: 1. Colleting cases of team members' past and present near miss and accidents(First data collection). 2. Quantifying the cases of near miss and accidents after identifying the degree of importance and urgency through surveys(Second data collection). 3. Quantifying cases and indentifying important points of contact through data analysis. 4. Making and standardizing a manual for important points of contact, and initiating participatory activities to prevent errors. 5. Activating web-based community for establishing the report system of near miss. 6. Estimating the result of before and after activities through surveys and focus group interviews. Results: 1) Quantified safety accidents and near miss in the department of nuclear medicine. About 50 near misses a month and one safety accident a year. 2) Establishing improvement measurements based on quantified data. About 11 participatory activities, the improvement of process, a manual for standardization. 3) Creating a system of safety culture and high participation rate of team members. Constructing a report system, making a check list and a slogan for safety culture, and establishing assessment index. 4) Activating communities for sharing the information of cases of near misses and accidents. 5) As the result of activities, the rate of near miss occurrence declined by 50% and the safety accident did not happen. Conclusion: The best service in the department of nuclear medicine is to provide patients with safety-guaranteed high-quality examination and cure. This research started from the question, 'what is the most faithful-to-the-basics way to provide the best service for patients?' and team members' common answer for this question was building a system with participation of all members. Building a system through the participatory improvement activities for preventing near miss and creating safety culture resulted in the 50% decline of near miss occurrence and no accident. This is a meaningful result from the perspective of advance management for patient safety. Moreover, this research paved the way for creating a culture to report and admit near miss or accidents by establishing a report system with no disadvantage of reporting. The system which sticks to the basics is the best service for patients and will form a patient safety culture system, which will lead to the customer satisfaction. Therefore, all members of the department of nuclear medicine will develop a differentiated patient safety culture with stabilizing the established system.

• Clinical and Experimental Pediatrics
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• v.58 no.2
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• pp.47-51
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• 2015

Debriefing is a conversational session that revolves around the sharing and examining of information after a specific event has taken place. Debriefing may follow a simulated or actual experience and provides a forum for the learners to reflect on the experience and learn from their mistakes. Originating from the military and aviation industry, it is used on a daily basis to reflect and improve the performance in other high-risk industries. Expert debriefers may facilitate the reflection by asking open-ended questions to probe into the framework of the learners and apply lessons learned to future situations. Debriefing has been proven to improve clinical outcomes such as the return of spontaneous circulation after cardiac arrest and the teaching of teamwork and communication in pediatrics. Incorporating debriefing into clinical practice would facilitate the cultural change necessary to talk more openly about team performance and learn from near misses, errors, and successes that will improve not only clinical outcome but also patient safety.

• Journal of the Korean Society of Safety
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• v.9 no.2
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• pp.26-32
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• 1994

It is quite similar in the current automated works likewise in the past manual works that single trivial human error and/or unsafe acts may lead to serious industrial accidents. Though the traditional approach for accident prevention focused on the serious injuries or losses, that was misleaded by failure of accident perception. As Heinrich pointed out, there are still enormous numbers of unsafe acts or near-misses before a real accident happen. Thus, for industrial accident prevention, a research on unsafe acts was committed. With accident data occurred during the last decade, statistics were analyzed for extracting behavioral characteristics. After that, a practical method Integrating AHP and statistics which shows possible accident factors and their priority at an individual factory was suggested. A computer program was developed also.

• Journal of the Korean Society of Safety
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• v.34 no.4
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• pp.68-75
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• 2019

As the tower crane accident emerged as a social issue in 2017, various government measures were prepared. Most of the measures are focused on erecting, climbing, and dismantling phases. Analyzes of 84 serious accidents related to tower cranes from 2000 to 2018 and 104 near misses accidents from 2016 to 2018 revealed that 50% of the serious accidents occurred during the operating phase. The main occupation influencing operating phase accidents was signalman(81.6% of serious accidents), whose communication and competency were governing causes. This result was the same in 294 questionnaires to signalmen. Signal systems and education policies for tower crane signalman in Korea and foreign countries were analyzed, and standardization of wireless signal system and improvement of education system were propose.

• Proceedings of the Korean Institute of Building Construction Conference
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• 2023.11a
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• pp.265-266
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• 2023

Recently, many disasters have occurred due to poor management of construction site. In addition, as legal regulations on safety management at construction sites are strengthened, its importance is being further emphasized. In relation to smart safety management technology, a study was introduced to build an analysis model through various safety-related data collected within construction companies. This model derives quantitative disaster risk about the site level through information related to past disasters and near misses. However, construction work is performed separately by work group of each partner company. There is a limitation in that individual workers cannot directly experience this analysis information. In this study, we propose a method to derive the safety disaster risk of individual work units from disaster risk of the site level. We expect that this study to be helpful for smart safety management technology of construction sites.

• Journal of Advanced Navigation Technology
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• v.15 no.6
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• pp.986-993
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• 2011

In this paper we consider the problem of the existing TCAS-II systems that fail to be satisfactory solution to mid-air collisions (MACs) and near mid-air collisions (NMACs or near misses). This is attributed to the fact that the earlier studies on the collision avoidance mainly have focused on determination logic of avoidance direction and vertical speed, reversal of the avoidance direction, multiple aircraft geometry, and availability in certain air spaces. But, the influence of sensor measurement errors on the performance of collision avoidance was not properly taken into account. Here we propose a new TCAS algorithm by using Kalman filter instead of '${\alpha}-{\beta}$' tracker to improve the avoidance performance under the influence of barometric sensor errors due to air-temperature, pressure leaks, static source error correction, etc.