Kaoru Sagara

Communication Error Determination System for Multi-layered or Chained Situations

Many medical accidents and incidents occurred due to communication errors. To avoid such incidents, in this paper, we propose a system for determining communication errors. Especially, we propose a model that can be applied to multi-layered or chained situations. First, we provide an overview of communication errors in nursing activities. Then we describe the warp and woof model for nursing task that was proposed by Harada and considers multi-layered or chained situations. Next we describe a system for determining communication errors based on the warp and woof model for nursing task. The system is capable of generating nursing activity diagrams semi-automatically and compiles necessary nursing activities. We also propose a prototype tagging of the nursing corpus for an effective generation of the diagrams. Then we combine the diagram generation with the Kamishibai KeyGraph to determine possible points of the hidden or potential factors of communication errors.

Scenario Violation As Gaps Between Activity Patterns

In this paper, we propose interactive and visual discovery method of hidden factors for accidents or incidents. Accidents or incidents tend to occur because of very small differences from an ideal situation. From the above viewpoint, we introduce scenario violation model and regard scenario violation as a gap from the proper scenario. Previously, we proposed abduction-based scenario violation determination strategy, but in this paper, we adopt the Kamishibai-KeyGraph to analyze multiple patterns at the same time. Then, we show a gap discovery procedure by using the Kamishibai-KeyGraph.