2 ( If anything can go wrong, it will. Things go wrong in batches. MiniMax (mini) (max) ( ) - 134 135 105 149 1) 2) 3) cf. cf. - 160-214 cf. - 211 209,210-204 vs 35 37-19 217 218-202 203 cf. - ( ) 104 ( ) - cf. 1
- 1) 643,644,656 2) cf. 709 719 ( ) 2
cf. <> - cf. - cf. 3
- vs. 29 300 ( ) 1) (To err is human.) 1) 2) ( ) 3) 4) 5) 6) cf. 2) ( ) ( ) ( ) 1) ( ) 2) Risk Management Patient Safety 3) Damage control: 1)Trouble shooting, 2)Risk-level, 80:20 4) 0.3% 5) 6) 7) 4
5
- http://www.umin.ac.jp/nuh_open/iryoujiko.htm cf. ( ) Crisis Management: Speed 6
- 7
(21 ) (18 ) vs 1) 8
2) - cf. 9
10
(1) (2) (3) (4) (5) 11
- - - ( or ) ( ) --------------------------------------------------------- ------------------------------------------------------------------------------------- GIO: SBOs:1) 2) 3) ( ) 4) ( ) 5) ( ) ------------------------------------------------------------------------------------- GIO:( ) SBOs:1) 2) 3) 4) ( ) ------------------------------------------------------------------------------------- GIO: SBOs:1) ( ( )) 2) ( ) 3) ( ) 12