• 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.

• Journal of the Korean Institute of Intelligent Systems
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• v.24 no.6
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• pp.603-608
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• 2014

In the maritime traffic environment, the near-miss between vessels is the situation approaching on collision course but collision accident is not occurred. In this study, in order to calculate the near-miss between navigating vessels, the discriminating equation using ship bumper theory and vessel position clustering methods are proposed. Applying proposed module to the vessel trajectories of the WANDO waterway, we assessment navigational risk factors of vessel type, navigational speed, meeting situation.

• Journal of the Korean Society of Safety
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• v.31 no.5
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• pp.177-186
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• 2016

When an event is occurred in a nuclear power plant (NPP), the NPP operator reports it referred by the regulation on reporting and public announcement of accidents and incidents. Some of the events do not need to be reported because they are not included in the reporting criteria of the regulation. However, it is necessary that they should be managed effectively because the accident can be occurred by the recurrence of a lot of them as precursors. Among the events not included in the reporting criteria of the regulation, near miss is the event that is not occurred but can generate a significant consequence. This can provide the cause of the event which does not result an accident. So, it is able to offer insightful knowledges to prevent higher level events about the function and process of NPP. The objective of this study is to analyze the issues of near miss events, prepare the defence against the risk, and improve the management process of NPP. To achieve it, this study performed to analyze the management structure and status of near miss events as well as the accident reporting system of the domestic and foreign regulation bodies. In case of Korea, the status was analyzed by quantitative data, licensee event reports and procedures. Based on these, we could find the causes that near miss events were not managed effectively. Then, systematic alternatives that reflected the perspective of man, technology and organization were drawn.

• Journal of Korean Academy of Nursing
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• v.49 no.5
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• pp.631-642
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• 2019

Purpose: This study aimed to predict the influencing factors and the consequences of near miss in nurses' medication error based upon Salazar & Primomo's ecological system theory. Methods: A convenience sample of 198 nurses was recruited for the cross-sectional survey design. Data were collected from July to September 2016. Using the collected data, the developed model was verified by structural equation modeling analysis using SPSS and AMOS program. Results: For the fitness of the hypothetical model, the results showed that $x^2$ ($x^2=258.50$, p<.001) was not fit, but standardized $x^2$ ($x^2/df=2.35$) was a good fit for this model. Additionally, absolute fit index RMR=.06, RMSEA=.08, GFI=.86, AGFI=.81 reached the recommended level, but the Incremental fit index TLI=.82, CFI=.85 was not enough to reach to the recommended level. With the path diagram of the hypothetical model, caution (${\beta}=-.29$ p<.001), patient safety culture (${\beta}=-.20$, p=.041), and work load (${\beta}=.18$, p=.037) had a significant effect on the near miss experiences in nurses' medication error, while fatigue (${\beta}=-.06$, p=.575) did not affect it. Moreover, the near miss experience had a significant effect on work productivity (${\beta}=-.25$, p=.001). Conclusion: These results have shown that to decrease the near miss experience by nurses and increase their work productivity in hospital environments would require both personal and organizational effort.

• 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.

• Transactions of the Korean Society of Mechanical Engineers A
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• v.38 no.12
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• pp.1325-1333
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• 2014

The dispersion pattern of a near miss neutralizer has a great effect on the disablement of a threatening projectile. This study numerically investigated the dispersion pattern of cylindrical tungsten impactors by an explosion in the near miss neutralizer. The mass and shape of the explosive were considered as influencing factors on the dispersion pattern. The explosives were set using two shape models: a parallel shape with the same upper and lower thicknesses and a tapered shape with different upper and lower thicknesses. In the simulation results, the dispersed impactors formed a ring-shaped pattern on a two-dimensional plane in an arbitrary space. In addition, the fire net area increased with the explosive mass when the explosive shapes were identical. In particular, the tapered shape explosive formed a larger fire net area than the parallel shape explosive. Based on the analysis of the fire net area along with the dispersion density, both the explosive mass and shape representing the physical characteristics should be considered for controlling the dispersion pattern of impactors in a near miss neutralizer.

• Progress in Medical Physics
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• v.27 no.3
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• pp.131-138
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• 2016

We analyzed the terminology and classification related to the risk management of radiation treatment overseas to establish the terminology and classification system for Korea. This study investigated the terminology and classification for radiotherapy risk management through overseas research materials from related organizations and associations, including the IAEA, WHO, British group, EC, and AAPM. Overseas risk management commonly uses the terms "near miss", "incident", and "adverse event", classified according to the degree of severity. However, several organizations have ambiguous terminologies. They use the term "near miss" for events such as a near event, close call, and good catch; the term "incident" for an event; and the term "adverse event" for the likes of an accident and an event. In addition, different organizations use different classifications: a "near miss" is generally classified as "incident" in most cases but not classified as such in BIR et al. Confusion might also be caused by the disunity of the terminology and classification, and by the ambiguity of definitions. Patient safety management of medical institutions in Korea uses the terms "near miss", "adverse event", and "sentinel event", which it classifies into eight levels according to the severity of risk to the patient. Therefore, the terminology and classification for radiotherapy risk management based on the patient safety management of medical institutions in Korea will help in improving the safety and quality of radiotherapy.

• Proceedings of the Korean Institute of Navigation and Port Research Conference
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• 2011.06a
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• pp.170-172
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• 2011

최근 ATLAS사(社)의 VTS 시스템에 통항분석 프로그램이 도입되었다. 통항분석 프로그램을 소개하고 이를 통한 통항량 및 통항 패턴분석과 Ship Near Miss, 선속에 따른 패턴을 분석하였다. 프로그램을 사용하면서 사용자입장에서 느낀 장 단점을 정리하고 개선방향에 대하여 정리하였다.

• International conference on construction engineering and project management
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• 2024.07a
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• pp.909-916
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• 2024

The emergence of Building Information Modelling (BIM), reality data, Virtual Reality (VR), and Augmented Reality (AR) has significantly enhanced the collaboration between stakeholders in construction management. The utilization of VR/AR devices holds considerable potential for monitoring safety in complex and constrained working environments on the construction site. On the other hand, near-miss incidents remain an important early sign of struck-by accidents. However, research on early warning and prevention methods for this risk is still limited. This paper, therefore, presents a framework for on-site and off-site collaborative safety monitoring framework using augmented and virtual reality for near-miss incidents. In the proposed framework, three phases to develop a VR/AR-based safety monitoring system include (1) construction safety simulation environment, (2) localization-based interaction system, and (3) safety monitoring system. The system can undertake the processing of data and enables communication among disparate VR/AR devices. VR clients are observational tools and offer guidance, while the AR client stays onsite for construction tasks. All clients connect to a processing computer, which also works as a host. The system embedded in the AR device can trigger an alarm or receive signals from the VR client when a near-miss issue happens. Additionally, all device clients possess the capability to share data acquired from onsite monitoring cameras, thereby fostering effective discussions and decision-making. The efficacy of this cross-platform system has been validated through the implementation of an outdoor coordination case study.

• Journal of the Korean Society for Aviation and Aeronautics
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• v.20 no.4
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• pp.84-90
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• 2012

Aviation Maintenance Technician(AMT)'s error is not directly link to deficiency which is differ to flight crew's error and it potentially maintains. Due to it usually occur as undesired aircraft state, hazards, like unreported maintenance error or near miss fortunately undetected and are not develop to accident. This could be a crucial influence of an accident occurrence. To remove these hazards, just safety culture should be support that anyone can report about safety problems and person who reported safety problems and hazards like near miss, should not get disadvantages. Also if it is satisfied, they must exempt for punishment and guaranteed for security. Hence, on this study, aviation maintenance site's just culture need to be researched and analysed about improvement for aviation maintenance field's positive just culture.