Research of knowledge structuring - to realize capture and application of the knowledge of casual chain to medical accident and action for it

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In this research we designed functions of the management system of structured knowledge for prevention of medical accident. As to realize the functions, we specified phase of process medical accidents likely to occur, captured the error of chain after the action for improvement, collected samples of them, and make to reduct the risk of introducing the chain. To collect information of process to medical accident, the system required as raw data from it, with the co-operation of two hospitals (medium and large scale) we designed the report system. And the system was introduced to establish the data storage for the required data.The management system of structured knowledge required 1. Design of framework of medical safety management system, and 2. Change management system supporting the entire hospital. As for 1, we designed medical management framework of the entire hospital and suggested it to previous hospitals to start the development of framework with existing one for best optimization. As for 2, we designed the model of change control system and examined it with self assessment sheet of ITIL service report managed by itSMF. The result was that almost every items were accepted and the score was highly above the average of medical cases.