• 한국의료질향상학회지
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• 제22권1호
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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.

• 한국안전학회지
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• 제37권2호
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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.

• 한국안전학회지
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• 제38권4호
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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.

• 한국건설관리학회논문집
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• 제20권4호
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• pp.69-76
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• 2019

본 연구는 토사운반작업이 실행되는 현장에 충돌위험구역을 설정하고 작업자의 불안전한 행동을 아차사고수준에서 식별하는 영상분석 방법론을 제시한다. 컴퓨터 비전기술을 건설안전관리에 활용하는 데 있어 큰 걸림돌이 되어 온 위험발생 이벤트를 연구자가 원하는 시나리오대로 재현하기 용이하도록 게임엔진을 활용하는 방법을 제시한다. 본 연구는 기존 연구들이 불안전한 조건을 결정론적으로 가정하는 접근방식과 달리, 현장여건에 따라 위험구역이 변화되는 상황을 현실적으로 반영하는 방법을 제시한다. 본 방법론은 선행연구들이 간과한 불안전한 조건과 행동을 구분하는 방법을 제시하고 사고가 발생되는 인과관계를 반영하였다. 사례연구는 덤프트럭에 의해 제공된 불안전한 조건하에서 작업자의 불안전한 행동을 아차사고 수준에서 관측하는 방법과 중점관리 대상이 되는 위험구역을 결정하는 방법을 규명하였다.

• 핵의학기술
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• 제14권2호
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• pp.138-144
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• 2010

급변하는 의료환경 속에서도 변함없이 의료기관들은 환자 안전관리 부분의 중요성을 인식하여 관리하고 있다. 하지만 현재 환자안전관리는 사후관리와 처벌이 강조된 프로세스들로 조직원들의 참여성이 결여된 문제를 보이고 있다. 본원 핵의학과 에서는 참여형 니어미스 사고예방 활동을 시행하여 환자안전사고에 사전관리를 시작하고 사고보고에 따른 불이익이 없는 시스템을 구축하여 니어미스 감소 와 환자안전사고 제로화를 목적으로 본 연구을 시작하였다. 또한 핵의학과만의 차별화된 환자안전관리System구축도 그 목적으로 하고 있다. 1. 팀원들의 과거 니어미스 및 현재 발생되고 있는 니어미스와 사고 사례수집(1차 자료수집). 2. 설문을 통해 중요도, 긴급도를 파악하고 니어미스 및 사고사례를 정량화(2차 자료수집). 3. 자료 분석을 통한 중요 접점 파악과 사고 사례 정량화. 4. 중요 접점 부분에 대한 매뉴얼 제작과 표준화, 오류방지를 위한 참여형 개선활동 시행. 5. 니어미스 보고체계 구축을 위한 웹 기반 커뮤니티 활동. 6. 설문과 FGI를 통해 활동 전후 평가 시행. 1) 비계량적이었던 핵의학과 내 안전사고 및 니어미스를 계량화(월 50여 회의 니어미스와 년 1건의 안전사고발생) 2) 계량화된 데이터를 통해 개선방안을 수립(0여건의 참여형 개선활동, 프로세스 개선, 표준화를 위한 약속 매뉴얼 제작) 3) 안전문화 시스템을 형성하고 팀원들의 높은 관여도를 형성.(보고체계구축, 체크리스트 제작, 안전문화 슬로건 제작, 평가 인덱스 구축) 4) 니어미스 및 사고 사례를 공유하고 반면교사로 삼기 위한 커뮤니티 개설. 5) 활동 전후 니어미스 발생률은 50% 감소 하였고 안전사고 제로. 핵의학과의 최고의 서비스는 환자안전이 보장된 양질의 검사와 치료를 제공하는 것이다. 참여형 개선활동으로 니어미스사고를 예방하고 안전문화를 형성하여 시스템을 구축함으로써 니어미스 발생 사례는 50% 줄었으며 안전사고는 발생하지 않았다. 이는 환자안전사고의 사전관리란 측면에서도 시사하는 바가 있다. 또한 불이익이 없는 사고보고체계도 마련하여 솔직하게 보고하고 인정하는 문화도 만든 계기가 되었다. 기본에 충실한 뛰어난 시스템은 환자에게 제공되는 최고의 서비스이며 형성된 안전문화 시스템은 결국 고객만족으로 이어질 것이다. 따라서 본원 핵의학과 에서는 마련된 시스템을 정착하고 안정시켜 차별화된 환자안전문화를 형성해 나가고자 한다.

• Clinical and Experimental Pediatrics
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• 제58권2호
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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.

• 한국안전학회지
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• 제9권2호
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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.

• 한국안전학회지
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• 제34권4호
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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.

• 한국건축시공학회:학술대회논문집
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• 한국건축시공학회 2023년도 가을학술발표대회논문집
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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.

• 한국항행학회논문지
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• 제15권6호
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• pp.986-993
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• 2011

현재 치명적인 항공기 공중충돌 사고 또는 니어미스 (Near miss) 사고를 예방하기 위해 국제표준으로 장착해 운용하고 있는 TCAS 시스템의 성능이 만족스럽지 못한 점에 대해 항공안전관련 기관의 관심이 집중되고 있다. 지금까지 TCAS의 충돌회피 성능개선에 대한 연구는 주로 회피방향, 수직상승속도, 회피방향의 역전, 복잡한 구도의 여러 항공기 및 회피공간의 여부 등에 대한 회피로직 개선에 집중되었다. 하지만 TCAS가 활용하는 정보의 신뢰성, 특히 고도계에서 발생할 수 있는 센서오차에 대해서는 주의 깊이 다루어지지 않았다. 따라서 본 논문에서는 고도계의 고도측정의 오차와 TCAS 충돌회피 알고리즘에 사용되는 '${\alpha}-{\beta}$' 추적기가 TCAS의 회피 성능에 미치는 영향을 분석하고 칼만필터를 사용하면 충돌회피 성능을 개선할 수 있음을 보이고자 한다.