{"created":"2023-07-25T10:08:49.229604+00:00","id":267,"links":{},"metadata":{"_buckets":{"deposit":"bc63bd7d-15c2-43a9-ab24-58ccab1579be"},"_deposit":{"created_by":5,"id":"267","owners":[5],"pid":{"revision_id":0,"type":"depid","value":"267"},"status":"published"},"_oai":{"id":"oai:jobu.repo.nii.ac.jp:00000267","sets":["7:17"]},"author_link":["267","269","266","265","270","268"],"item_10002_biblio_info_7":{"attribute_name":"書誌情報","attribute_value_mlt":[{"bibliographicIssueDates":{"bibliographicIssueDate":"2008-03-31","bibliographicIssueDateType":"Issued"},"bibliographicPageEnd":"36","bibliographicPageStart":"27","bibliographicVolumeNumber":"3","bibliographic_titles":[{"bibliographic_title":"上武大学看護学部紀要. 2008, vol.3, p.27-36"},{"bibliographic_title":"Jobu Daigaku Kango Gakubu kiyo (Bulletin of Faculty of Nursing, Jobu University). 2008, vol.3, p.27-36","bibliographic_titleLang":"en"}]}]},"item_10002_description_5":{"attribute_name":"抄録","attribute_value_mlt":[{"subitem_description":"看護師がリー脳症でで入院中の患者の人工呼吸器の加湿用に使用する蒸留水とエタノールとを取り違えたことによって、看護師数名がエタノールを人工呼吸器に補給し、患者が急性アルコール中毒により死亡したという事故が発生した(2000年2月28日〜3月2日)。 その事件では3つの判決が下されている(2008年1月30日現在)が、その裁判書から事実を抽出し、ヒューマンファクタ工学の分析手法により分析を加えた。そのヒューマンファクタ工学の分析手法は、実際になされた各行為を時系列で表にした上で、本来あるべき行為との比較をしてズレを特定し、次にそのズレについてなぜなぜ分析で背景要因を要求するというものである。鉄道総研により提唱された。分析の結果、6つの逸脱が明らかとなり、そのうち4つは逸脱意図のない違反であった。\nTo use for a respirator's humidifier, a nurse mistakenly brought a plastic tank with ethyl alcohol instead of one with distilled water. As a result, the patient who had contracted Leigh syndrome died from acute alcohol poisoning. The accident happened from February 28th to March 2nd in 2000. For this accident, three judgments were rendered in the courts until January 30th in 2008. Using the facts extracted from these three judgment documents, we analyzed the accident by a method designed in human factor engineering by Railway Technical Research Institute. In this method, firstly, you make a table of temporal sequence of actual acts and compare with acts that have to be done originally. Secondly, you pursue the factors leading to an aberration or a variation found out by the comparison with why-why analysis. The results showed six aberrations or variations in this accident. Four out of six were violations, that are intentional aberrations or variations.","subitem_description_type":"Abstract"}]},"item_10002_publisher_8":{"attribute_name":"出版者","attribute_value_mlt":[{"subitem_publisher":"上武大学看護学部"}]},"item_10002_relation_12":{"attribute_name":"論文ID（NAID）","attribute_value_mlt":[{"subitem_relation_type_id":{"subitem_relation_type_id_text":"110007151090","subitem_relation_type_select":"NAID"}}]},"item_10002_source_id_9":{"attribute_name":"ISSN","attribute_value_mlt":[{"subitem_source_identifier":"1880-747X","subitem_source_identifier_type":"ISSN"}]},"item_creator":{"attribute_name":"著者","attribute_type":"creator","attribute_value_mlt":[{"creatorNames":[{"creatorName":"奥津, 康祐"},{"creatorName":"オクツ, コウスケ","creatorNameLang":"ja-Kana"}],"nameIdentifiers":[{"nameIdentifier":"265","nameIdentifierScheme":"WEKO"}]},{"creatorNames":[{"creatorName":"安藤, 郁子"},{"creatorName":"アンドウ, イクコ","creatorNameLang":"ja-Kana"}],"nameIdentifiers":[{"nameIdentifier":"266","nameIdentifierScheme":"WEKO"}]},{"creatorNames":[{"creatorName":"滝沢, 美智子"},{"creatorName":"タキザワ, ミチコ","creatorNameLang":"ja-Kana"}],"nameIdentifiers":[{"nameIdentifier":"267","nameIdentifierScheme":"WEKO"}]},{"creatorNames":[{"creatorName":"OKUTSU, Kosuke","creatorNameLang":"en"}],"nameIdentifiers":[{"nameIdentifier":"268","nameIdentifierScheme":"WEKO"}]},{"creatorNames":[{"creatorName":"ANDOU, Ikuko","creatorNameLang":"en"}],"nameIdentifiers":[{"nameIdentifier":"269","nameIdentifierScheme":"WEKO"}]},{"creatorNames":[{"creatorName":"TAKIZAWA, Michiko","creatorNameLang":"en"}],"nameIdentifiers":[{"nameIdentifier":"270","nameIdentifierScheme":"WEKO"}]}]},"item_files":{"attribute_name":"ファイル情報","attribute_type":"file","attribute_value_mlt":[{"accessrole":"open_date","date":[{"dateType":"Available","dateValue":"2023-02-04"}],"displaytype":"detail","filename":"747-03-027.pdf","filesize":[{"value":"948.5 kB"}],"format":"application/pdf","licensetype":"license_note","mimetype":"application/pdf","url":{"label":"747-03-027","url":"https://jobu.repo.nii.ac.jp/record/267/files/747-03-027.pdf"},"version_id":"b020162e-3211-4ddf-bce5-a9d5efbec2eb"}]},"item_keyword":{"attribute_name":"キーワード","attribute_value_mlt":[{"subitem_subject":"aberration or variation","subitem_subject_scheme":"Other"},{"subitem_subject":"human error","subitem_subject_scheme":"Other"},{"subitem_subject":"violation","subitem_subject_scheme":"Other"}]},"item_language":{"attribute_name":"言語","attribute_value_mlt":[{"subitem_language":"jpn"}]},"item_resource_type":{"attribute_name":"資源タイプ","attribute_value_mlt":[{"resourcetype":"departmental bulletin paper","resourceuri":"http://purl.org/coar/resource_type/c_6501"}]},"item_title":"ヒューマンファクタ工学の観点からの事例分析 : 消毒用エタノール取り違え事故裁判例から","item_titles":{"attribute_name":"タイトル","attribute_value_mlt":[{"subitem_title":"ヒューマンファクタ工学の観点からの事例分析 : 消毒用エタノール取り違え事故裁判例から"},{"subitem_title":"An analysis of the accident in which nurses mistakenly supplied a respirator with ethyl alcohol : from human factor engineering's point of view","subitem_title_language":"en"}]},"item_type_id":"10002","owner":"5","path":["17"],"pubdate":{"attribute_name":"公開日","attribute_value":"2023-02-04"},"publish_date":"2023-02-04","publish_status":"0","recid":"267","relation_version_is_last":true,"title":["ヒューマンファクタ工学の観点からの事例分析 : 消毒用エタノール取り違え事故裁判例から"],"weko_creator_id":"5","weko_shared_id":-1},"updated":"2023-07-25T10:12:26.572478+00:00"}