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

本研究对医疗事故预防结构化知识管理系统的功能进行了设计。为了实现这一功能，我们明确了过程中可能发生医疗事故的阶段，并在行动后捕获了链条的错误进行改进，并收集了这些错误的样本，以降低引入链条的风险。为了收集医疗事故过程的信息，系统需要将其作为原始数据，在两家大中型医院的合作下，我们设计了报告系统。并介绍了该系统建立所需数据的数据存储。所需要的结构化知识管理系统2.医疗安全管理系统框架设计；改变整个医院的管理系统。对于1，我们设计了整个医院的医疗管理框架，并建议之前的医院从现有的框架开始开发，以达到最佳的优化。对于2，我们设计了变更控制系统模型，并使用itSMF管理的ITIL服务报告自评表对其进行了检验。结果是几乎每个项目都被接受，得分远高于医疗案例的平均水平。

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.