{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,2]],"date-time":"2025-08-02T16:18:54Z","timestamp":1754151534152,"version":"3.41.2"},"reference-count":20,"publisher":"Japanese Society of Radiological Technology","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nippon Hoshasen Gijutsu Gakkai Zasshi","Jpn. J. Radiol. Technol."],"published-print":{"date-parts":[[2025]]},"DOI":"10.6009\/jjrt.25-1534","type":"journal-article","created":{"date-parts":[[2025,7,14]],"date-time":"2025-07-14T22:09:02Z","timestamp":1752530942000},"page":"n\/a","source":"Crossref","is-referenced-by-count":0,"title":["Implementation Report: Attempt for a Decision of Priorities in Measures to Prevent Recurrence of Low-level Incidents Using Priority Monitoring Score","\u5b9f\u65bd\u5831\u544a\uff1a\u4f4e\u30ec\u30d9\u30eb\u30a4\u30f3\u30b7\u30c7\u30f3\u30c8\u306b\u5bfe\u3059\u308b\u91cd\u70b9\u76e3\u8996\u30b9\u30b3\u30a2\u3092\u7528\u3044\u305f\u518d\u767a\u9632\u6b62\u7b56\u306e\u512a\u5148\u5ea6\u6c7a\u5b9a\u306e\u8a66\u307f"],"prefix":"10.6009","volume":"81","author":[{"given":"Makoto","family":"Sasaki","sequence":"first","affiliation":[{"name":"Division of Clinical Radiology Service, Kyoto University Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isao","family":"Yamaguchi","sequence":"additional","affiliation":[{"name":"Department of Radiological Science, Faculty of Health Science, Morinomiya University of Medical Sciences"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yoshihiro","family":"Kitoh","sequence":"additional","affiliation":[{"name":"Radiology Division, Shinshu University Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tsuyoshi","family":"Ueyama","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Tokyo Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ryuhei","family":"Iwaki","sequence":"additional","affiliation":[{"name":"Department of Radiology, Iwate Medical University Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Naomi","family":"Nishio","sequence":"additional","affiliation":[{"name":"Department of Radiological Technology, Japanese Red Hospital Aichi Medical Center Nagoya Daini Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tetsuo","family":"Kida","sequence":"additional","affiliation":[{"name":"Ritto Clinic"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Koji","family":"Koizumi","sequence":"additional","affiliation":[{"name":"Division of Clinical Radiology Service, Kyoto University Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hidemichi","family":"Kawata","sequence":"additional","affiliation":[{"name":"Department of Radiological Science, Faculty of Health Sciences, Junshin Gakuen University"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"4040","reference":[{"key":"1","unstructured":"1\uff09\u2003Kohn LT, Corrigan JM, Donaldson MS, et al. To err is human: building a safer health system. National Academies Press, Washington, 2000, 1\u20138."},{"key":"2","unstructured":"2\uff09\u2003\u85e4\u6df5\u4fca\u738b\uff0c\u675c\u4e0b\u6df3\u6b21\uff0e\u7b2cII\u7de8\u3000\u8a3a\u7642\u653e\u5c04\u7dda\u6280\u5e2b\u306e\u305f\u3081\u306e\u533b\u7642\u5b89\u5168\u7ba1\u7406\uff0e\u653e\u5c04\u7dda\u30fb\u533b\u7642\u5b89\u5168\u7ba1\u7406\u5b66\uff0e\u5357\u5c71\u5802\uff0c\u6771\u4eac\uff0c2020, 249\u2013304."},{"key":"3","doi-asserted-by":"crossref","unstructured":"3\uff09\u2003Huq MS, Fraass BA, Dunscombe PB, et al. The report of task group 100 of the AAPM: application of risk analysis methods to radiation therapy quality management. Med Phys 2016; 43: 4209\u20134262.","DOI":"10.1118\/1.4947547"},{"key":"4","doi-asserted-by":"crossref","unstructured":"4\uff09\u2003Koike D, Yamakami J, Miyashita T, et al. Combining failure modes and effects analysis and cause\u2013effect analysis: a novel method of risk analysis to reduce anaphylaxis due to contrast media. Int J Qual Health Care 2022; 34: 1\u20139.","DOI":"10.1093\/intqhc\/mzac002"},{"key":"5","doi-asserted-by":"crossref","unstructured":"5\uff09\u2003Kim J, Miller B, Siddiqui S, et al. FMEA of MR-only treatment planning in the pelvis. Adv Radiat Oncol 2019; 4: 168\u2013176.","DOI":"10.1016\/j.adro.2018.08.024"},{"key":"6","doi-asserted-by":"crossref","unstructured":"6\uff09\u2003Nishioka S, Okamoto H, Chiba T, et al. Identifying risk characteristics using failure mode and effect analysis for risk management in online magnetic resonance-guided adaptive radiation therapy. Phys Imaging Radiat Oncol 2022; 23: 1\u20137.","DOI":"10.1016\/j.phro.2022.06.002"},{"key":"7","doi-asserted-by":"crossref","unstructured":"7\uff09\u2003Nishioka S, Okamoto H, Chiba T, et al. A universal worksheet for failure mode and effects analysis-A project of the Japanese College of Medical Physics. Med Phys 2024; 51: 3658\u20133664.","DOI":"10.1002\/mp.17033"},{"key":"8","unstructured":"8\uff09\u2003Warnick RE, Lusk AR, Thaman JJ, et al. Failure mode and effects analysis (FMEA) to enhance the safety and efficiency of Gamma Knife radiosurgery. J Radiosurg SBRT 2020; 7: 115\u2013125."},{"key":"9","doi-asserted-by":"crossref","unstructured":"9\uff09\u2003Taylor PA, Miles E, Hoffmann L, et al. Prioritizing clinical trial quality assurance for photons and protons: a failure modes and effects analysis (FMEA) comparison. Radiother Oncol 2023; 182: 109494.","DOI":"10.1016\/j.radonc.2023.109494"},{"key":"10","unstructured":"10\uff09\u2003\u56fd\u7acb\u5927\u5b66\u9644\u5c5e\u75c5\u9662\u9577\u4f1a\u8b70\u5e38\u7f6e\u59d4\u54e1\u4f1a\uff0e\u56fd\u7acb\u5927\u5b66\u9644\u5c5e\u75c5\u9662\u306b\u304a\u3051\u308b\u533b\u7642\u4e0a\u306e\u4e8b\u6545\u7b49\u306e\u516c\u8868\u306b\u95a2\u3059\u308b\u6307\u91dd\uff08\u6539\u8a02\u7248\uff09\uff0e\u5e73\u621024\u5e746\u6708\uff0ehttps:\/\/nuhc.jp\/wp-content\/themes\/NUHC\/Portals\/0\/images\/activity\/report\/sgst_category\/safety\/kohyosisin201206.pdf\uff082024\u5e746\u670810\u65e5\u78ba\u8a8d\uff09\uff0e"},{"key":"11","doi-asserted-by":"crossref","unstructured":"11\uff09\u2003Reason J. Human error: models and management. BMJ 2000; 320: 768\u2013770.","DOI":"10.1136\/bmj.320.7237.768"},{"key":"12","unstructured":"12\uff09\u20032023\u5e74\u5ea6\u65e5\u672c\u653e\u5c04\u7dda\u6280\u8853\u5b66\u4f1a\u533b\u7642\u5b89\u5168\u59d4\u54e1\u4f1a\uff0e\u533b\u7642\u5b89\u5168\u30d5\u30a9\u30fc\u30e9\u30e0\u30a2\u30f3\u30b1\u30fc\u30c8\u7d50\u679c\uff0ehttps:\/\/www.jsrt.or.jp\/data\/wp-content\/uploads\/2023\/09\/955885d84cf24d530897d0f30c2f5462.pdf\uff082025\u5e745\u670820\u65e5\u78ba\u8a8d\uff09\uff0e"},{"key":"13","unstructured":"13\uff09\u2003\u5c71\u8c37\u88d5\u54c9\uff0c\ud844\ude3d\u4e95\u53f8\uff0c\u5bae\u897f\u5fe0\u53f2\uff0c\u4ed6\uff0e\u653e\u5c04\u7dda\u79d1\u306b\u304a\u3051\u308b\u8ee2\u5012\u4e8b\u6545\u306e\u5b9f\u614b\u3068\u9632\u6b62\u306e\u305f\u3081\u306e\u6539\u5584\u70b9\u306e\u63d0\u6848\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022019; 75: 1337\u20131346."},{"key":"14","unstructured":"14\uff09\u2003\u9db4\u7530\u88d5\u8f14\uff0e\u5f53\u9662\u306b\u304a\u3051\u308b\u5b89\u5168\u5411\u4e0a\u306b\u5411\u3051\u305f\u53d6\u308a\u7d44\u307f\uff5e\u30a4\u30f3\u30b7\u30c7\u30f3\u30c8\u4e8b\u4f8b\u5206\u6790\u3068FMEA\u306e\u5b9f\u8df5\uff5e\uff0e\u653e\u7dda\u6cbb\u7642\u304b\u305f\u308d\u3046\u4f1a\u8a8c\u20022022; 27: 9\u201316."},{"key":"15","unstructured":"15\uff09\u2003\u5c71\u7530\u525b\u53f2\uff0c\u6749\u6fa4\u6b66\u4fca\uff0c\u6751\u4e95\u6f64\u4e00\u90ce\uff0e3.4\u76f8\u95a2\u4fc2\u6570\uff0eR\u306b\u3088\u308b\u3084\u3055\u3057\u3044\u7d71\u8a08\u5b66\uff0e\u30aa\u30fc\u30e0\u793e\uff0c\u6771\u4eac\uff0c2008, 62\u201364."},{"key":"16","unstructured":"16\uff09\u2003\u5c71\u672c\u92ed\u4e8c\u90ce\uff0c\u5ca1\u8015\u5e73\uff0e\u653e\u5c04\u7dda\u6cbb\u7642\u306b\u304a\u3051\u308b\u30a4\u30f3\u30b7\u30c7\u30f3\u30c8\u4e8b\u4f8b\u306b\u5bfe\u3059\u308bVTA\u3092\u7528\u3044\u305f\u30d2\u30e5\u30fc\u30de\u30f3\u30d5\u30a1\u30af\u30bf\u7814\u7a76\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022019; 75: 1249\u20131259."},{"key":"17","unstructured":"17\uff09\u2003\u6c38\u5409\u8aa0\uff0c\ud844\ude3d\u4e95\u53f8\uff0c\u5c71\u8c37\u88d5\u54c9\uff0c\u4ed6\uff0e\u653e\u5c04\u7dda\u691c\u67fb\u90e8\u9580\u3067\u306e\u60a3\u8005\u8ee2\u5012\u30a2\u30f3\u30b1\u30fc\u30c8\u8abf\u67fb\u304b\u3089\u5f97\u3089\u308c\u305f\u77e5\u898b\u2014\u8ee2\u5012\u4e8b\u6545\u306b\u3088\u308b\u91cd\u50b7\u5ea6\u3092\u4e2d\u5fc3\u3068\u3057\u3066\u2014\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022019; 75: 1308\u20131315."},{"key":"18","doi-asserted-by":"crossref","unstructured":"18\uff09\u2003\ud844\ude3d\u4e95\u53f8\uff0c\u6cb3\u672c\u6e05\u6f84\uff0c\u5c71\u53e3\u548c\u4e5f\uff0e\u533b\u7642\u5b89\u5168\u306b\u5bfe\u3059\u308b\u8a8d\u8b58\u30ec\u30d9\u30eb\u3068\u7d4c\u9a13\u5e74\u6570\u306b\u3088\u308b\u5dee\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022012; 68: 608\u2013616.","DOI":"10.6009\/jjrt.2012_JSRT_68.5.608"},{"key":"19","doi-asserted-by":"crossref","unstructured":"19\uff09\u2003\u6a4b\u7530\u660c\u5f18\uff0c\u767d\u77f3\u9806\u4e8c\uff0e\u8a3a\u7642\u653e\u5c04\u7dda\u6280\u5e2b\u306e\u696d\u52d9\u306b\u95a2\u9023\u3057\u305f\u30a4\u30f3\u30b7\u30c7\u30f3\u30c8\u30ec\u30dd\u30fc\u30c8\u2014\u904e\u53bb10\u5e74\u9593\u5206\u306e\u89e3\u6790\u7d50\u679c\u2014\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022015; 71: 99\u2013107.","DOI":"10.6009\/jjrt.2015_JSRT_71.2.99"},{"key":"20","unstructured":"20\uff09\u2003\u5ca9\u672c\u5927\u6210\uff0c\u798f\u5cf6\u5eb7\u5b8f\uff0c\u677e\u4e0b\u77e9\u6b63\uff0c\u4ed6\uff0e\u8a3a\u7642\u653e\u5c04\u7dda\u6280\u5e2b\u7d4c\u9a13\u5e74\u6570\u306b\u7740\u76ee\u3057\u305f\u5358\u7d14X\u7dda\u64ae\u5f71\u306b\u304a\u3051\u308b\u30a4\u30f3\u30b7\u30c7\u30f3\u30c8\u5206\u6790\uff0e\u65e5\u653e\u6280\u5b66\u8a8c\u20022019; 75: 1331\u20131336."}],"container-title":["Japanese Journal of Radiological Technology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.jstage.jst.go.jp\/article\/jjrt\/81\/10\/81_25-1534\/_pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,19]],"date-time":"2025-07-19T03:32:59Z","timestamp":1752895979000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.jstage.jst.go.jp\/article\/jjrt\/81\/10\/81_25-1534\/_article\/-char\/ja\/"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025]]},"references-count":20,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2025]]}},"URL":"https:\/\/doi.org\/10.6009\/jjrt.25-1534","relation":{},"ISSN":["0369-4305","1881-4883"],"issn-type":[{"type":"print","value":"0369-4305"},{"type":"electronic","value":"1881-4883"}],"subject":[],"published":{"date-parts":[[2025]]},"article-number":"25-1534"}}