• Journal of the Korean Society of Safety
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• v.27 no.5
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• pp.164-170
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• 2012

In this study, a new technique for detecting near miss using 4M risk assessment method is suggested. Until now, the safety education with instances of near miss has just been progressed in most industrial settings, without any systematic guideline. By menas of appling 4M risk assessment method, the organized technique, which could effectively manage the fundamental prevention of industrial accident in advance, is developed. The organized technique of near miss-management suggested in this study will take an effective role in basically expanding the application of risk assessment method, as well as in contributing the activity of zero-accident as a safety guideline in hazardous workshops.

• 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.

• 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 Korea Safety Management & Science
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• v.8 no.2
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• pp.13-23
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• 2006

The present study has investigated the patterns and the causes of safety -accidents on the accident-data in semiconductor Industries through near miss report the cases in the advanced companies. The ratio of incomplete actions to incomplete state was 4 to 6 as the cases of accidents in semiconductor industries in the respect of Human-ware, Hard- ware, Environment-ware and System-ware. The ratio of Human to machine in the attributes of semiconductor accident was 4 to 1. The study also investigated correlation among the system related to production, accident, losses and time. In semiconductor industry, we found that pattern of safety-accident analysis is organized potential, interaction, complexity, medium. Therefore, this study find out that semiconductor model consists of organization, individual, task, machine, environment and system.

• Proceedings of KOSOMES biannual meeting
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• 2017.11a
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• pp.118-118
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• 2017

• 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 Korea Society for Simulation
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• v.27 no.1
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• pp.119-126
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• 2018

This study intended to exploratively testify human error causing factors for railway traffic controller, using AMOS structural equation model. Through literature survey, fatigue and stress as exogenous variable, errors in information process such as cognitive, memory, storage, and execution error as endogenous variable, and accident and incident(near-miss) as dependent variable were set up. Results based on AMOS using 201 railway traffic controllers' questionnaire showed that a clear causality loop like as 'stress ${\rightarrow}$ memory error ${\rightarrow}$ storage error ${\rightarrow}$ incident(near-miss) ${\rightarrow}$ accident' is formed. This result suggests that for the purpose of mitigation of traffic controller's accident, it is so necessary to reduce memory and execution error in the information processing process based on the effective management of stress, as the precedent of them.

• Journal of the Society of Disaster Information
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• v.19 no.1
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• pp.216-230
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• 2023

Purpose: The purpose is to prevent accidents by predicting disasters through the analysis of near-miss. Method: In this study, a near-miss literature review and data were collected at construction sites, and a questionnaire survey was conducted to use logistic regression analysis and decision tree analysis to classify the possibility of near-miss connection. Result: As a result of analyzing the effects of near-miss types on mental, physical, and safety habits and behaviors, the factor with a high influence on the body is the need for near-miss management, the type of job is electricity·information communication, and health status in order, and the mental factor is the construction scale The influence was high, and the factors with the highest influence on the habit behavior factors were analyzed in the order of experience, number of serious injuries, and occupation in order of illusion, inappropriate work instructions, and body parts. Through decision tree analysis, factors and patterns that affect the possibility of a near-miss being a surprise accident were identified. Conclusion: Construction site officials consider the observation of near-miss and mentally and physically. Specific management of the relevance of physical aspects to near-miss should be implemented, and a work environment in which serious accidents are reduced is expected through personnel allocation, work plans, work procedures and methods, and feedback so that inappropriate work instructions do not lead to near-miss.

• 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 KOSOMES biannual meeting
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• 2017.11a
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• pp.117-117
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• 2017