ヒューマンエラー防止のための 外的手がかり利用の
Contents
1.2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15. tolerant
16. Ts Tr 5 9 Ts
17. hindering
18. Blomquist 1986 U U I Dee ple s L e 8
19. 31
20. 67
21. Hollnagel prevention protec tion boundaries prevention prevention bound aries boundaries restraining keeping together dissipating hindering prevention protection
22. 11 20 Dekker 2006 Hollnagel 1994
23. Hollnagel Hollnagel x 80 65 3 3 3 1 Habraken amp Schaaf 2010 52 127 11 2 4 planned failure planned miss planned absent unplanned failure 74 26
24. 143
25. 2002
26. 6 G H H Epstein 1994 REI Rational Experiential Inventory Pacini amp Epstein 1999 2004 132
27. 146 7 2
28. Swain amp Guttman 1983 Performance Shaping Factor PSF PSF Inattentional blindness change blindness Chabris amp Simons 2010 2011 2008
29. bn c 12 0 low confidence 2 I high confidence o er 10 eo G B 8 c 2 6 no punishment punishment 6 4 4 6 4 3 2 13 df 1 66 F 99 df 1 66 3 70 4 1 66 lt 10 6 4 4 24 63 df 1 66 lt 05 F 2 17 df 1 66 45 df 1 66 8 6 4 1 P4 Wilcoxon 1 63 6 4 4 00
30. 3 tolerant 4 5 611 0000 6 1 1 x 6 1 1 b 95 9 5 11 10 6 1 1 b HELP 1 0 6 1 1 b 4 4 1 414 4 4
31. 6 3 1 6 3 2 6 3 2 b 6 3 6 3 2 33 lt 001 15 n s 6 3 3 a 6 3 3 b F 3 17 df 2 85 lt 05 102 4 38 df 5 85
32. 212 Hollnagel 1999 control barriers safety barriers boundaries Hollnagel Hollnagel 2 1 1 2004 2008 IU 100 2008 ID 10 Physical system Functional system Symbolic system Incorporeal system contain restrain cohesion 100 100 100000 prevent hinder dampen dissipate counter regulate indicate pe
33. 2006
34. Incentive Usefulness Cost 5 6 Usefulness Cost Usefulness Cost 5 2 3 5 5 5 6 Potential Drive x Incentive 5 7 Potential Subjective Confidence x Deficit Stress x Usefulness Cost 5 8
35. 6 8 3 31 27 19 21 13 Fujitsu FMV 6740CL7S FMV6667SL6O CRT iiyama LS501U 57007 12 10 6 8 4 6 8 2 6 8 1 6 8 1 128
36. 2000 2003 2001 2002 2004 2005 2003 20110 12 169
37. 42
38. 7 3 7 3 0000000000 DD DD DD B D
39. 74 0 000000000 1 153 741 JO0000000000000000
40. 112 00000
41. 6 7 2 1 1 4 5 2 5 7 12 3 15 12 12 40 4 8 6 4 18 By 4 72 6 2r 27 27 81 F 6 1904 2 520 lt 01 4 190df 2 59 lt 05 6 7 6 2002 FOK feeling of knowing FOK FOK
42. 19439303 res sAyd 7002 6661 8 otr oqui s ulojs s TILLTEG 7007 6007 86861 661 jnoxoo UNO 8861 ueurioN 013409 SuruTeA 861 sarrepunoq Ayoyes SIoLLTeq 01 UOD 10139930 1d 0014293014 ut que 19109 IOLIH ETE 45
43. 65 44
44. Fujitsu FMV466D3S1 15 Fujitsu FMV DP84Z 18 10 6 63 6 6 1 10 69 df 1 11 p lt 01 3 60 df 2 22 p lt 05 x F 3 23 df 4 44 lt 05 x 3 69 df 2 22 p lt 05 F 7 16 df 2 22 lt 01 5 42 2 22 05 Tukey
45. Stress Usefulness Cost Subjective Con fidence Cost 81 0 73 Deficit Usefulness Usefulness 135 712 HHHHHUHHHHH
46. 070 0000
47. 119 6 67 HHHHHHHHHHHHHHHHHHHH 6 7 1 DD
48. Tukey Fs gt 6 23 df 1 11 lt 05 6 6 2 3 89 df 2 22 p lt 05 7 53 df 2 22 lt 01 Tukey 6 6 3 5 94 df 2 22 lt 01 Tukey 117 6 6 4 Number of clicking the targets Icon 0s Icon
49. 4 4 5 18 1 9 8 10 0 28 45 0 0 0 0 45 45 29 4 19 11 15 0 49 26 3 13 8 17 0 41 8 0 0 0 0 8 8 16 1 12 6 9 0 28 38 5 28 18 13 0 64 40 3 15 10 7 16 51 7 2 2 1 2 2 9 227 19 98 62 73 71 323 100 0 8 496 43 2 27 3 32 2 31 3 227 8 4 43 2 27 3 0 0 32 2 31 3 53 53 71 53 227 53 9 7 Ol AT x 4 6 44 5 4 5 451 0000000000000000 0 227 72
50. 157 743 0 0000000 O
51. 53 monitoring
52. 155 7 4 1
53. Lamisil Lamictal 1000cc
54. 3 4 1 59 35
55. 6 7 1 9 11 26 9 47 42 9 79 42 9 89 47 10 16 58 10 21 47 10 37 68 10 42 63 10 63 74 18 6 7 1 6 7 4 180 23 6 7 1 122 6 7 a high difficulty b middle difficulty c low difficulty
56. 6 SONYH 5 000 300 10 1 6 4 3 00 19 16 180 17 6 4 2 F 2 77 df 1 66 n s F 1 76 df 1 66 n s 5 36 df 1 66 lt 05 106 6 4 3 Mean frequency of using help Go no punishment 6 4 0 low confidence high confidence punishment
57. 127 HHHHHHHHHHHHHH 32
58. 4 3 1 4 3 1 2000 N 30 L IVH IVH IVH 63 4 3 1
59. Losses Successive layers of defences barriers and safeguards 2 1 1 Reason et al 2001 1985 poka yoke control warning 1985 control warning control warning Norman 1988 1990 control Hollnagel 2004 2006 2008 Hollnage 2 1 2 40 2 Prevention control barriers Initiating event incorrect action 1 Error tolerant a ak
60. 5 000 10 100 50 6 3 3 6 3 1 0 0 6 3 1 b 5 37 df 1 85 lt 05 8 63 df 2 85 lt 001 2 40 df 5 85 p lt 05 101 Mean frequency help use Delay time of help 05 15 35 The number of confirmation trials a no punishment Delay time of help e 0s 0 1 2 3 4 5 6 The number of confirmation trials b punishment
61. 6 7 2 20 50
62. 104 6 4 2 gt AE HD H Me MBL
63. 159 2007 160 0000 1 15 E 5 x
64. Step M 4STEP M 11 1 2 3 4 5 6 7 8 9 10 11 2 4 5 2 122 Hollnagel Sharit Hollnagel prevention protection boundaries error resistant Sharit human fallibility context improvement prevention protection boundaries improvement 44 Error tolerant 2 1 Suryedissip 3urweagso1 Surequoo
65. 6 5 2 20 22 x Direct Coordinates Fujitsu FMV466D3S1 15 Fujitsu FMV DP84Z 110 6 5 18
66. 39 2 Error tolerant Some holes due to active failures 7 N gt Hazards Other holes due to latent conditions resident pathogens
67. FAN y DIAA 2 388 va PAY CFM CARS 5 scored VEE 2E HOR OR RR
68. 7 5 2000
69. 443 00000000000000 69
70. 4 70 df 2 4 p lt 10 12 01 df 2 4 p lt 01 26 25 df 4 8 p lt 01 Tukey 5 6 2 4 6 2 2 6 2 3 6 2 4 6 2 5 99 6
71. 30 1 2
72. 6 2 1 5 5 8 Potential A Subjective Confidence x Deficit Stress 6 1 x Use fulness Cost Subjective Con fidence Cost Usefulness Potential k x A Subjective Confidence x Cost 6 2 A Subjective Confidence Cost Potential k x Drive x Incentive 6 3
73. 713 0 00000000 187
74. 115 00000000000000 Senders amp lead
75. 6 1 1 Potential 615 HHHHHHHHHH 6 1 1 Subjective Con fidence Cost Deficit Usefulness Usefulness 93 62 0000000000000000000000
76. 113 6 5 2 5
77. 5 Blomquist 1986 Blomquist U I D e s ple s 7 3 L L p U L p p 136 7 1 7 3 7 D pL
78. 127
79. permission communication permission 33 00000000 55 3 3 1
80. 10 6 8 5 FO GOH A D E C B 3 43 2 98 t 1 98 df 22 p 060 24 31 75 131
81. 108 6 5 65 HHHHHHHHHHHUHHHHHHHHHHH
82. Rasmussen 1986 1990 Reason 1990 working definitions 1 1 1 1994 1999 10 1 1 expected consequence accepted decision or ti unexpected action interaction consequence unaccepted expected decision or consequence action unexpected consequence human error 1 1 1
83. 6 8 1 0000000000 00000 HH 000000 0000000 REIN re 000000 9 H3 H3 9 6 3 0 B 000000000 8 000 000 9 5 35 C 0000000000000 3 H3 H3 9 7 3 3 D 2 HO H3 9 6 3 2 E 00000000 2 HO H3 9 4 2 7 00000000 2 HO H3 9 1 3 2 6 0000 2 000 000 9 4 33 000000 3 00000 9 6 32 HOHHHHHHHHHHHHHH H3HHHHHHHHHHHHHH 0000000000000000 D E F D H 14000 180 10 H 130
84. 151
85. 5 CF BR Barrier Removal P Prescribed Behavior CS CS BR CS P B BR C BR B BR 0 5 13 B 5 14 CF BR CF P D BR CF BR CF P Vi if 5 CS P gt 0 then B BR CS BR CS P C BR 0 else B BR 0 C BR 5 CS BR 5 13 if gt 0 then D BR CF BR CF P i else D BR 0 5 14 Usefulness Cost Deficit
86. 144 7 2 72 HHHHHHHHHH 4
87. 13 EFE TS zum ER A b
88. Rasmussen 1986 amp Reason 1990
89. 126 6 8 RELI VIER A og 3 gt
90. Holl nagel preventing orman 1988 1990 Gibson 1979 1986 contain Hollnagel
91. 534 HHHHHHHHHHH Atkinson Blomquist L p D Deficit BCD BCD BCD if then BCD 88 064 0000000000000 61 00000
92. 141
93. 2 1 Error tolerant 1985 1985 1986 amp Godfrey 2005 error resistant error tolerant 2009 00 2 3 4 5 6 7 8 9 2009 error resistant error resistant error tolerant 214 0000000 1999 H2 GUIDE Hiyari Hatto GUideline for IDeas of Error reduction 43 2 Error tolerant
94. 4 3
95. OE el 143 le a ee hI 145 721 EE EET DE ET EE ET DET DE DP D seere ese see 145 122 REGE RR 148 723 JOOOOOO00O000000000000000 149 NE ee 151 13 4 EEE Ste nd oet eet o opta 151 7 3 2 EPIRI B B s r se AEE 152 J PG ska Fa Ma ek ee 153 741 000000000000000000 154 1 4 2 157 7 43 L TJ d m RR RARE 158 TNI UULTUS 159 161 169 0 1 HHHHHHHHH 0 2 000000
96. Sanders amp McCormick 1987 Reason 1990 Error will be taken as a generic term to encompass al 1 those occasions in which planned sequence of mental or physical fails to achieve its intended outcome and when these failures cannot be attributed to the intervention of some chance agency
97. 23 123 00000000 USB
98. 79 050 0 0 00000000 000 51 000000 5 1 1 Hull 0000 Hull
99. 4 5 6 4 6 71 000000000000000 5 6 711 000000 5 Potential Drive x Incentive 7 1 Potential Subjective Confidence x Deficit Stress x Usefulness Cost 7 2 Drive Incentive Subjective Con fidence Deficit 134 7 1
100. 57 2003 2004 34 0000000 341 O00000 00000000
101. 154 7 4
102. 6 5 1 F 8 63 df 1 4 p lt 05 F 3 46 df 2 8 p lt 10 6 5 1 6 5 2 P5 6 5 3 10 Wilcoxon 112 6 5 4 Mean frequency of use Mean number of clicking targets 6 5 O Direct Coordinates P1 P2 P3 P4 P5 Participants O Direct M Coordinates 1 3 5 Number of confirmation trials 6 5 3
103. 13 13 140 7 1
104. 6 4 2 15 5 0 low confidence Em high confidence 50 10 3 o x u 2 5 no punishment punishment 6 4 1 Participant No no punishment punishment 2 4 5 P6 P7 10 0 10 0 9 4 9 6 8 0 7 8 6 8 10 0 10 0 10 0 9 2 9 2 8 2 8 6 107
105. 612 HHHHHUHHHHHHUHHHHH 90 1 6 1 6 1
106. IT Bates 2000 Bates amp Gawande 2003 714 JO00000000000000 13
107. 6 6 1 1 b 64 16 20 20 10 18 10 10 6 2 3 10 6 2 2 6 2 3 6 2 1 6 2 Cost Cost C 96 6 2 Delay time of help 05 15 CD D 0 1 2 3 4 5 Mean frequency of using help The number of confirmation trials Delay time of help e 05 gt 15 35 Mean frequency of using help 2 0 1 0 0 0 1 0 2 0 Subjective evaluation z value 6 2 3
108. 37 tolerant error resistant error tolerant resilient system Reason 2008 2010 error tolerant error tolerant
109. 142 7 1 716
110. 2002 SHEL m SHEL 4M 4E Medical SAFER RCA J HPES 4M 4E SHEL 4M 4E NASA M Man Machine Media Management E Education Engineering Enforcement Example 4E M E SHEL Hawkins 1987 1992 Liveware Software Hardware Environment Liveware 4M 4E HEL SHEL m SHEL 1994 Patient P mSHELL 2002 2001 4M 4E SHEL SHEL 6M 5E 76 4 5
111. Rasmussen 1986 slip mistake 1996
112. a 3 1 1 3 1 1 2 2 1 plan of action decision 32 HHHHHHHHH object symbol document others 3 2 1 3 Hollnagel 3 2 1 object 3 2 1
113. 2010 147 2011 722 HHHHHHHH
114. OU 113 00 00000 1 1
115. 111 Mean frequency of help use 4 ee O Direct Coordinates 1 3 5 Number of confirmation trials
116. 444 00000000 A A 445 HHHHHHHH
117. human fallibility context 33 132 HHHHHHHHHHH
118. 6 6 2 UU 12 10 20 22 Icon lick HELP
119. 11 00000000000 human error 111 0000000 error
120. 34 133 JU D lU 00000000000 Tversky amp Kahneman 1974 2008
121. 103 64 0000000000000 6 41 00
122. 1 1 6
123. 221 HHHHHHHHH prevention protection boundaries prevention protection boundaries boundaries boundaries prevention protection Sharit 1 3 1
124. 74 452 000000000 00000 4 5
125. 1 2 5 0000000 27 1 2 5 28
126. vendi ed Handbook of Human Factors Wiley Interscience Pp 219 250 2003 1 10 55 62 1985a 15 41 50 19855 1 15 78 87 1986 2 16 4 13 Clapp amp Godfrey 2005 35 74 81 2008 69 15 159 60 61 62 63 64 65 66 67 68 69 70 2000 Norman 1981 Categorization of action slips Psychological Review 88 1 15 Norman D A 1988 The
127. Reason J T 1990 Human error Cambridge University Press J 1994 Reason J T 1997 Managing the Risks of Organizational Accidents J 1999 Reason 2000 Human error models and management British Medical Jour nal 320 768 770 Reason J T Carthey J amp de Leval 2001 Diagnosing Vulnerable System Syndrome An Essential Prerequisite to Effective Risk Management Quality in Health Care 10 Suppl 2 21 25 165 72 73 74 75 76 77 78 79 80 81 82 83 84 85 166 Reason J T 2008 The Human Contribution Unsafe Acts Accidents and Heroic Recoveries Ashgate Publ
128. 114 HHHHHH Senders amp 1991 error means that something has been done which was not intended by the actor not desired by a set of rules or external observer or that led the task or system outside its acceptable limits
129. JCAHO RCA Root Cause Analysis variances adverse events sentinel events RCA RCA Wald amp Shojania 2001 2002 2004 ex 20010 Wald amp Shojania 2001 4M 4E SHEL RCA error resistant 4M 4E SHEL RCA Error resistant 77 Error tolerant 454 HH
130. 4 4 6 18 4 86 87 44 26 66 74 90 20 65 65 60 36 85 95 A 2 8 42 34 29 26 11 4 10 40 32 26 40 36 14 5 8 5 12 21 1 40 4 9 29 1 20 133 73 78 100 100 100 100 4 5 1 Hollnagel 2004 2006 High High Medium Low Long Medium Long Medium Short 31 3 9 7 Hollnagel Hollnagel efficiency implementation delay 4 5 1 90 65 0 A 32 73
131. 64
132. 700 o3 0000000 0 4
133. 115
134. 16 1 2 Basic Error Type 1 1 1 1 1 1 1 5 NEN Violation v 1 2 1 Unsafe acts by Reason 1990 Zhang
135. 66 HHHHHHHHHHHHHHHHHHHHHHHH 6 6 1 114 6 6
136. 1956 1982 E gHgxDxkK H habit E excitatory potential S stimul Hull 1952 1971 Spence 5 1 R response Hull 5 1 dri
137. 73 1 0000 000000 Holl nagel
138. Reason Reason 1990 1994 Unsa fe acts violation 1 2 1 rman Norman Reason Rasmussen 1986 1990 generic error modeling system
139. Error resistant error tolerant tolere error resistant error 22 1 2
140. 1 2 3 2008 e e e Swain amp Guttman 1983 Norman 1981 Reason 1990 Zhang et al 2004 2008 2003 20
141. 6 4 2 19 22 SONY PCV R73K 15 Mitsubishi MDT151X
142. 1 2 6 HHHH 0000 00000 1 2 2 29 Ecco 1 2 2
143. error resistant Error resistant error tolerant error tolerant fail soft rn fault tolerant
144. 700 700 300 2007a
145. 4 5
146. PHS PHS 68 4 4 3 4 4
147. 52 3 2 323 O00000 document countering indicating
148. Eccless J 5 amp Wigfield A 2002 Motivational beliefs values and goals Annual Review of Psychology 53 109 132 Epstein 5 1994 Integration of the cognitive and the psychodynamic unconscious American Psychologist 49 709 724 2002 112 119 161 12 13 14 15 16 17 18 19 20 21 22 23 24 25 162 1989 Sensation Seeking Scale Abstract Expression 60 180 183 Gibson J J 1979 The Ecological Approach to Visual Perception Psychology Press J J 1996
149. 1998 144 148 2000 12 52 58 2000 2002 61 147 151 2002 Root Cause Analysis 51 142 149 2010 167 100 Zhang J Patel V L Johnson T R amp Shortliffe 2004 cognitive tax onomy of medical errors Journal of Biomedical Informatics 37 193 204 101 Zechmeister E B amp Johnson J E 1992 Critical thinking A functional approach Brooks Cole E B J E 1996 102 Zuckerman amp Kuhlman 2000 Personality and risk taking Common biosocial factors Journal of Personality 68 999 1029 168
150. protection 60 040 000000000000000 0 00000000 41 2006
151. 04 000000 0 5 000000 010 000000000000
152. 7 4 1 156
153. 42 UUUU 4 2 1 18 45 29 26 16 38 40 227
154. error resistant error tolerant resistant error tolerant error resistant Sharit 2006 resistant error tolerant 1 3 6 000000000 error tolerant error resistant resistant error tolerant
155. 168 169 2010 34 8 5 12 2011 7 1 14 Miller amp Swain 1987 Human error and human reliability In Sal
156. EIL JES LL TL TL TESI LILILIECIEIBIL IE BUUSUUBU C TL TL C mim I A 00000000 0000000 LILILIBILIISE IL s le see m 6 7 1 26 6 7 1 6 7 5 6 7 2 9 41 df 2 780 0 lt 01
157. 89 4 oe a m SNARES Wet Eta 1000080 05000008 Kamm HELP 1 0 4 4 1 00600000 00000106 Dei 00000 00000000 0000001 0000001 O 0000000 b
158. error resistant error tolerant error tolerant 38 02 Error tolerant O00 2 1 Error tolerant error tolerant error tolerant 211 HHHHHHHHH Reason 2000 person approach syste
159. BCD 87 BCD
160. Hull Potential Drive x Incentive value 5 3 5 2 1 Subjective Con fidence probability deficit Risk Perception Probability x Deficit 5 4 Probability A Subjective Con fidence 82 5 2 Drive A Subjective Confidence x Deficit Stress 522 5 5
161. Tukey 116 8 99 df 2 22 p lt 01 6 6 m Icon Os Icon s 4 R click 0s R click 1s e Space 0s o Space 1s Frequency of using help 1 3 5 Number of confirmation trials 6 6 1
162. Pp 131 132 2001 2008 69 14 2001 1999 1999 Pp 117 130 1996 4 121 130 2002 2004
163. 10 6 5 3 F 3 15 df 2 8 lt 10 2 400 2 77 2 87
164. 200211 2004 2006 11 Minimum encounter Minimum probability Multiple det Minimum damage
165. 7 4 742 0000 00000 00000 00000 000 000
166. 15 ATS Activation Trigger Schema ATS Swain amp Guttman Norman Swain amp Guttman
167. 6 8 Rescaled Distance Cluster Combine 15 20 25 10 0 CASE ALS Ma a Label A 2 C XO M OLO O lt F r NM CO SIE LO LON SLOP c Or ON r ON NO O 1 ER 1 1 1 CO Ost lt O lt F OT LO L LO OLD e CGI Mode L V Or MEE VON LO r LS LO lt F CN DO lt CO LG lt O 0 b CO CN CO r LO O c gt O Or L O C gt NA rmt r DER lt m 0 I Label
168. 11 005 250 30 500 55 1800 54 4 21 Fujitsu FMV 6740CL7S FMV6667SL6C CRT iiyama 185010 5700 1 27 18 6 7 3 HHHHH 19 17 190 21 121
169. 4 4 1 4 4 4 4 41 00000 66 4 4 1 4 4
170. 2006 http naruto hsp jp top img pd 2009 f FMAl_report pdf 1988 1992 2008 1999 15013407 Pp 21 29 2006 1995 37 337 366 43 Lindsay H amp Norman D A 1977 Human Information Processing Introduction to Psychology 2nd edition Academic Press Inc
171. 18 1 2 2 1 2 Zhang et al 2004
172. 47 Error tolerant error tol erant 48
173. 53 000000000 84 5 3 5 3 1 Atkinson Atkinson Atkinson 1957 Atkinson Litwin 1960
174. tolerant 034 0 0 0000000000000 00000 tolerant tolerant
175. 9 Hendrich Bender amp Nyhuis 2003 1999 C C B C A C B Reason 1990 1994 75 45 3 JIOO0000000000000
176. 6 8 2 129
177. Grudin 1992 93
178. prevention 58 ER protection 3 4 1 342 00000000000
179. 1 41 46 92 Wears R amp Nemeth C P 2007 Replacing hindsight with insight Toward better understanding of diagnostic failures Annals of Emergency Medicine 49 206 209 93 Weiten W 2010 Psychology Themes and Variations Briefer Edition 8 edition Wadsworth Publishing Pp 396 397 94 95 96 97 98 99
180. 121 0 00000000000000 Swain amp Guttman Swain Guttman 1983 Error of Omission Error of Com mission Extraneous act Sequential Error Time Error Norman Norman 1981 mistake slip
181. 2003 43 0000 62 4 3
182. 1 22
183. 80 120 6 7
184. 6 3 HHHHHHHHHHHHHH 6 3 1 6 3 2 21 22 100 6 3
185. 24
186. 4 4 OO 45
187. 26 2005
188. 8 05 df 4 76 6 7 3 123 o 7 lt 6 difficulty high 5 middle
189. Grudin J 1992 Utility and usability Research issues and development contexts Interacting with Computers 4 209 217 Habraken M M P amp van der Schaaf T W 2010 If only filed missed and absent error recovery opportunities in medication errors Quality and Safety in Health Care 19 37 41 2003 2004 23 46 1994 8 19 24 Hawkins 1987 Human Factors in Flight Gower Technical Press Ltd 1992 Hendrich A L Bender 9 amp Nyhuis A 2003 Validation of the Hendrich II Fall Risk Model A large concurrent case contr
190. 10 21 22 NEC PC 9821 Xn C9W 15 NEC PC KD854 NECH 10 10 12 10 95
191. error tolerant error resistant 36 1 3 resistant error tolerant
192. 1996 erroneous actions 117 0000000000000
193. 125 es 000000000000000000 6 81 00 682 HHHHHHH
194. JCO 148 7 2 723 HHHHHHHHHHHHHHUHHHHHHHHH 2008
195. 94 6 2 Behavior potential low cost middle high low Sub jective confidence high 6 2 1 62 2
196. 1985 0 0 Spence K W 1956 Behavior Theory and Conditioning Yale University Press K W 1982 2009 39 479 491 Swain D amp Guttman E 1983 Handbook of human reliability analysis with emphasis on nuclear power plant applications NUREG CR 1278 Washington DC NRC 1991 ET 39 39 40 2002 73 243 250 1994
197. 71 4 4 5 71 70 4 4 4
198. Lindsay amp orman 1977 3 3 3 0000000000000 2003 33 4 HHHHHHHHHH
199. Norman Zhang SHEL 122 000000000000000
200. Holl nagel IC 2009 2010 150
201. 17 1 2 1 Zhang et 2004
202. 134 0 00 error tolerant 35 tolerant resistant error tolerant resistant 1 3 5 Error resistant 0 0 0 error tolerant Error resistant error tolerant
203. 6 8
204. 12 1 1
205. Frequency of help use k x A Subjective Con fidence x 3 delay of help C 6 4 F 133 8 df 3 6 lt 01 F 47 74 df 3 6 lt 01 0 81 73 97 Mean number of target click 0 1 2 3 4 5 6 The number of confirmation trials 6 2 4 C o Delay time of help e 05 15 35 5 8 2 0 10 0 0 1 0 2 0 Subjective evaluation z value 6 2 5 u 10
206. 331 00000000000 33 2 56 3 3
207. 44 6 00000 71
208. 6 4 1 6 4 2 6 4 3 6 4 4 6 5 1 6 5 2 6 5 3 6 5 4 6 6 1 6 6 2 6 6 3 6 6 4 6 7 1 6 7 2 6 7 3 6 7 4 6 7 5 6 7 6 6 8 1 6 8 2 6 8 3 6 8 4 6 8 5 iv 7 11 7 1 2 7 1 3 7 1 4 7 1 5 134 2 7 3 7 4 7 5
209. 7 32 000000000 152 7 4
210. 1 2 4 0000000000 25 1986
211. 7 2 1 OOOO OOO 0000000000000 145
212. 48 20 10 10 12 10 12 10 10 20 614 5 8 Subjective Con fidenc Deficit Usefulness Cost Stre 92 6 1
213. PERAS 1 1 2 USB 1 1 2a 14 1 2 12 00000000000
214. 1983 P H 163 45 46 47 48 49 150 151 52 93 94 95 96 97 98 164 2001 65 346 2003 67 769 2004 49 72 2007a 53 14 17 20075 71 553 2009
215. 5 1 1 5 1 2 Hull EJ 4 4 s a Sees asa t d Fo Ca a a S B 2 5 2 1 5 2 2 5 2 3 5 3 1 5 3 2 5 3 3 5 3 4 Atkinson El EF EF EEEE EE EE E sr se e W eS 0000000 Benefit Cost Deficit 6 2 6 3 6 1 1 6 1 2 6 1 3 6 1 4 6 1 5 6 2 1 6 2 2 6 2 3 6 2 4 6 3 1 6 3 2 111 6 4 6 5 6 6 6 7 6 8 6 3 3 6 3 4
216. VAI ELVA 3 MAGE Cm 1 3 1 Sharit 2006 1 3 NM 13 HHHHHHHHHHHHHHHH Sharit 2006 1 3 1 SharitHHHH Sharit 2006
217. Zhang Patel Johnson amp Shortliffe 2004 Norman Zhang 1 2 1 1 2 2 Reason Rasmussen 2008 1 2 3
218. 19
219. 2 22 3 1 3 2 3 3 3 4 3 5 3 2 1 3 2 2 3 2 3 3 2 4 3 3 1 3 3 2 3 3 3 3 3 4 3 4 1 3 4 2 4 1 4 2 4 3 4 4 4 4 1 4 4 2 4 4 3 4 4 4 39 39 39 39 42 43 44 46 46 47 50 50 91 51 93 93 94 55 56 56 57 57 58 58 59 60 4 5 4 4 5 4 4 6 4 5 1 4 5 2 4 5 3 4 5 4 4 5 5 5 2 5 3
220. 5 9 Ms Ps Is 5 10 Mg x Ps x Ig 5 10 Atkinson Is 1 Ps Ts Ms x Ps x 1 Ps 5 11 5 11 1 2 O 1 1 2 Atkinson Atkinson 85 5 3 2 BlomquistHHHHHHHH
221. 46 2 2 gt r error tolerant 222 HHHHHHHHHHH tolerant resistant
222. tolerant 31 0000000000 external 2001 Rasmussen 1986 1990 3 2
223. 5 low 4 5 3 5 9 2 1 gt 0 2 3 4 5 Subjective evaluation 6 7 2 w 11 5 10 gt 59 difficulty 4 A oo high gt 8 5 middle low c 7 6 2 3 4 5 Subjective evaluation 6 7 3 10 160df 2 780 lt 01 9 46 4 76 lt 01 6 7 2 429 p lt 01 124 6 7
224. 6 8 2001 2001 1995 2000 idges 1994
225. 0 a Atkinson J W 1957 Motivational determinants of risktaking behavior Psycho logical Review 64 359 372 Atkinson J amp Litwin 1960 Achievement motive and test anxiety conceived as motive to approach success and motive to avoid failure Journal of Abnormal and Social Psychology 60 52 63 Bates D W 2000 Using information technology to reduce rates of medication errors in hospitals British Medical Journal 320 788 791 Bates D W Gawande A A 2003 Improving safety with information technol ogy The New England Journal of Medicine 348 2526 2534 Blomquist 1986 A utility maximization model of driver traffic safety be havior Accident Analysis and Prevention 18 371 375 Caplan R A Posner K L amp Cheney F W 1991 Effect of outcome on physi cian judgments of appropriateness of care The Journal of the American Medical Association 265 1957 1960 Chabris amp Simons D 2010 The Invisible Gorilla And Other Ways Our Intuitions Deceive Us Crown Archetype 2011 2 Dekker S 2006 The Field Guide to Understanding Human Error Ashgate Pub lishing Limited 5 2010
226. Human Factors TOPICS 86 2004 200 85 92 CEST 87 Tversky amp Kahneman D 1974 Judgment under uncertainty Heuristics and biases Science 185 1124 1131 88 Vroom 1964 Work and motivation New York Wiley 89 Wald H amp Shojania K G 2001 Root Cause Analysis In K G Shojania B W Duncan K M McDonald R M Wachter and A J Markowitz Eds 90 91 Making Health Care Safer Critical Analysis of Patient Safety Practices Ev idence Report Technology Assessment Number 43 AHRQ Publication No 01 E058 July 2001 Agency for Healthcare Research and Quality Rockville MD http www ahrq gov clinic ptsafety index html 51 56 1999 ICU ISP 6 361 367 2003 0 0
227. 0000000000000 00000000000000 000 0 1 0 2 0 3 0 4 0 5 1 1 1 1 1 1 1 1 2 1 1 3 1 1 4 1 1 5 1 1 6 1 1 7 1 2 1 2 1 1 2 2 1 2 3 1 2 4 1 2 5 1 2 6 1 2 7 1 3 1 3 1 Sharit 1 3 2 1 3 3 1 3 4 1 3 5 Error resistant 1 3 6 wow N OO DD Q 2 2 Error tolerant Error tol erant 2 1 1 2 1 2 2 1 3 2 1 4 2 1 5 2 2 1
228. prescribing incorporeal 3 24 others 54 3 3
229. 3 0000 0000 91
230. 5 12 1 D pl L 8 Blomquist 8 U e U dU de 0 5 p U 1988 L Deficit p Subjective Con fidence D Cost 5 3 3 Benefit Cost Deficit BCD Polet Vanderhaegen amp Millot 2009 Benefit Cost Deficit 86 5 3
231. 6 5 1 00 109
232. Psychology of Everyday Things Basic Books D A 1990 2004 43 85 91 2005 c Pacini R amp Epstein S 1999 The relation of rational and experiential informa tion processing styles to personality basic beliefs and the ratio bias phenomenon Journal of Personality and Social Psychology 76 972 987 Polet P Vanderhaegen F amp Millot P A 2009 Human behaviour analy sis of barrier deviations using a Benefit Cost Deficit model Advances in Human Computer Interaction Vol 2009 Article ID 642929 10 pages Rasmussen J 1986 Information Processing and Human Machine Interaction Approach To Cognitive Engineering Elsevier Science Publishing J 1990
233. a a a E i EN Accident ll i AA DA 1 MIN KO SG EI GAA Protection Protection safety boundaries Active or passive barrier functions that prevent the initiating event from occurring Active barrier Passive barrier functions that deflect functions that minimise 1 1 1 1 1 A barriers 1 1 1 consequences consequences
234. lt 01 Mean frequency of help use Sub jective evaluation 2 value 6 3 Delay time of help e 05 15 35 punishment punishment Delay time help 1 e 05 15 35 Sub jective evaluation 2 value 6 3 2 Mean number of target clicks 0 1 2 The number of confirmation trials Delay time of help e s s 35 3 4 5 6 0 1 punishument 6 34 DU 6 3 3 Delay time of help 2 3 b punishment e 0s s 35 4 5 The number of confirmation trials
235. 1s 4 R click 0s R click 1s e Space 0s o Space 1s 5 8 7 6 5 Number of confirmation trials 6 6 2 m Icon Os Icon 1s 4 R click 0s R click 1s e Space 0s o Space 1s 3 5 2 gt 3 0 lt o o 2 5 2 o 5 2 20 1 3 5 Number of confirmation trials 6 6 3 6 6 3 118 6 6
236. 2 Error tolerant warning control error toler error resistant error tolerant error tolerant Reason 2000 system approach 2 2 error tolerant 00000 error tolerant
237. 6 2 4 6 2 5 98 6 2
238. 8 7 1 7 1 5 D 000000 00000000 139
239. HHHUHHHHHLH 4 55 78 4 5
240. U Posner amp Cheney 1991 21 Wears amp Neme 158 7 5
241. ishing Limited J 2010 Sasou amp Reason J T 1999 Team errors Definition and taxonomy Reliability Engineering and System Safety 65 1 9 Schneider W amp Shiffrin 1977 Controlled and automatic human infor mation processing 1 Detection search and attention Psychological Review 84 1 66 Scheier M F Carver C S amp Bridges M W 1994 Distinguishing optimism from neuroticism and trait anxiety self mastery and self esteem a reevaluation of the Life Orientation Test Journal of Personality and Social Psychology 67 1063 1078 Senders J W amp Moray N P 1991 Human error cause prediction and reduction LEA Hillsdale New Jersey Sharit J 2006 Human error In Gavriel Salvendy ed Handbook of Human Fac tors and Ergonomics Wiley Pp 708 760 2003 33 372 380 2002 43 428 429
242. m approach Reason Reason Reason 2000 Reason Carthey amp de Leval 2001 active failures latent conditions 2 1 1 defences bar riers safeguards Reason
243. ol study of hospitalized patients Applied Nursing Research 16 9 21 Hollnagel E 1994 Human Reliability Analysis Context and Control Academic Press E 1996 Hollnagel E 1999 Accident and Barriers 7th European Conference on Cognitive Science Approaches to Process Control Pp175 180 Villeneuve d Ascq France Hollnagel E 2004 Barriers And Accident Prevention Ashgate Publishing Lim ited E 2006 Hollnagel 2008 Risk barriers safety Safety Science 46 221 229 Hull C L 1952 Behavior System An Introduction to Behavior Theory Yale University Press C L 1971 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 1998
244. rmission communication comply prescribing Hollnagel 1000000000 41 Error tolerant Hollnagel 2008 Barrier system Barrier function Physical Functional Symbolic Incorporeal Contain or protect Restrain Cohesion Separete Prevent hard Prevent soft Hinder Dampen Dissipate Counter Regulate Indicate Permission Communication Comply Prescribing Norman 213 00000000 error proof Hollnagel fool
245. vation Expectancy x Value Value Hull Vroom 1964 Eccles amp Wigfield 2002 Expectancy 52 0000
246. ve K incentive Hull 512 HHHHHHH Moti
Download Pdf Manuals
Related Search