10月の勉強会

今月の勉強会は「福祉用具を安全に利用する…ヒヤリハット事例から学ぶ」がテーマ。
テクノエイド協会発行の「福祉用具を安全に利用するためのハンドブック」を
資料として、要因分析のグループワークを行いました。



ひとつの出来事からたくさんの要因を探っていきます。
分析の手法はいろいろあるようですが、今回は「なぜなぜ分析」で要因を出したものを
「MSHELL手法」を使って分類し、それぞれに対策を考えました。

起こった出来事を「なぜ起こってしまったのか」と考えます。
たくさんの「なぜ・なぜ」を繰り返し対策にたどりつきます。



グループで意見を出し合うので、個人の考えだけではなく
それぞれが気が付いたことを知ることができます。
「そんなこともあるのか」と自分の気づき以外もたくさん出てきて…。
そしてまた出された要因を、次の「なぜ・なぜ」に繋げます。

福祉用具のヒヤリハットであっても、福祉用具だけが要因ではなく
そこには介助者・環境・本人・管理などと、様々な要因があります。
ヒヤリハット事例が起こったとき、要因を分けて考えることで
見逃しがなくなります。

最後にグループごとに対策をまとめたものを発表しました。





事故予防のためには、ルールを決め守ること、人(個人)の努力に頼らない
対策を考えることが大切だということがわかりました。

1件の重大事故の陰には300件のヒヤリハット事案が隠れているという
ハインリッヒの法則。
起こった出来事を話し合い、今日のような分析を行って
ヒヤリハットの数を減らす努力を忘れず、日々取り組んでいきたいと思います。







コメント
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<b>How the Ukrainian clinic BioTexCom deceived its clients</b>

Hello anyone. The team of journalists found a lot of customers, which BioTexCom deceived. We managed to searc dissatisfied customers. We are deceived customers of BioTexCom company of reproductive medicine. When was the new event with them, when organization diddled people, we wish to write as much critiques as it probable and to support them. We did a great job and search a lot of certificate of negative feedback of organization BioTexCom. All of them you should search in network on request "biotexcom notices". We want to support them and help them. With our columnist help, fewer folk will turn to deceivers.

Beneath you should search data from man who have fallen in atmosphere, which were bound with BioTexCom services.

They asked columnists to assistance them. Oliver and Jane help them and together we are searching data and processed it. With suggest columnist assistance they compose this story. Thanks for the help Oliver and Jane.

When immature families haven’t opportunities to have children, they turn to the surrogacy companies. Some of them are placed in Eastern Europe. One of the well-knowns reproductive medicine clinic is BioTexCom. There are some of people in Europe, who use cater for of them. If to read biotexcom researches, is it probable to find any of privative researches.

At last this company became known cause of they don't utilize DNA one of parents. This clinic makes some of operation without required circumstances. Some of people from Spain, Estonia, Romania are visit Ukraine and pick up children.

You can read information from Cecilia Rizzika, who is Italian advocate. He see that at first his customers in 2010 come to firm and visit clinics. At clinic medic provided a surrogate mother, who shall impregnate with the cum of the future parent, but semen wasn’t involved. About situation future parents received evidence after test. Outlay of operation was 30.
<b>Shame of Ukrainian surrogate medicine</b>

Hello anyone. The team of columnists searched a lot of clients, which BioTexCom deceived. We managed to find dissatisfied clients. We are cheated buyers of BioTexCom clinic of reproductive medicine. When was the renewed event with them, when BioTexCom diddled them, we want to write as much reviews as it probable and to support them. We did a splendid operation and find a lot of certificate of negative feedback of company BioTexCom. All of them you should find in network on request "biotexcom reviews". We want to lend a hand them and help them. With our columnist help, fewer folk will turn to tricksters.

Below you can search information from humans who have fallen in atmosphere, which were combined with BioTexCom services.

They asked journalists to assistance them. Oliver and Jane help our team and in team we are finding data and reviewed it. With suggest journalist support they compose this story. Thanks for the help Oliver and Jane.

When youthful fathers haven’t posibilities to have babies, they turn to the surrogacy clinics. A lot of them are situated in Eastern Europe. One of the famous reproductive medicine companies is BioTexCom. There are some of people in Poland, who use cater for of them. If to examine biotexcom reviews, is it probable to find a lot of negative reviews.

Last time this company became famous cause of they don't utilize DNA one of people. This firm makes some of operation without necessary conditions. Some of humans from Italy, Estonia, Romania are visit Ukraine and pick up babies.

You can view reviews from Cecilia Rizzika, who is Italian advocate. He see that at first his customers in 2010 come to firm and visit institution. At organization doctors provided a surrogate mother, who shall impregnate with the semen of the future parent, but sperm wasn’t keep on. About situation future mom get information after test. Value of procedure was 30.000 euros.

<a href=ht
<b>How the Ukrainian clinic BioTexCom deceived its clients</b>

Hi everybody. The team of columnists searched a lot of customers, which BioTexCom deceived. We managed to searc dissatisfied clients. We are cheated clients of BioTexCom clinic of reproductive medicine. When was the renewed occasion with them, when BioTexCom diddled people, we want to write as much notices as it possible and to help them. We did a splendid job and search many of certificate of negative feedback of clinic BioTexCom. All of them you can search in network on request "biotexcom notices". We want to lend a hand them and help them. With our journalist help, fewer people will turn to deceivers.

Below you should find information from humans who have fallen in atmosphere, which were bound with BioTexCom services.

They asked journalists to help them. Oliver and Jane help them and together we are finding information and processed it. With suggest journalist assistance they compose this story. Thanks for the support Oliver and Jane.

When young fathers haven’t chances to have children, they approach to the surrogacy companies. Many of them are located in Eastern Europe. One of the well-knowns reproductive medicine firms is BioTexCom. There are a lot of people in Europe, who use cater for of them. If to examine biotexcom surveys, is it probable to find any of malevolent reviews.

At last this company became known cause of they don't utilize DNA one of parents. This company makes many of operation without necessary conditions. A lot of humans from Spain, Poland, Hungary are visit Ukraine and pick up children.

You could view information from Cecilia Rizzika, who is Italian advocate. He observed that at first his clients in 2010 get to company and visit institution. At clinic doctors provided a surrogate mom, who shall impregnate with the sperm of the future parent, but cum wasn’t comprised. About situation future parents get evidence after DNA test. Cost of procedure was
<b>Scandalous incident with the Ukrainian clinic of surrogate medicine</b>

Hello everybody. The team of columnists searched a lot of clients, which BioTexCom deceived. We managed to find dissatisfied clients. We are diddled buyers of BioTexCom clinic of reproductive medicine. When was the new occasion with them, when BioTexCom diddled people, we wish to write as much critiques as it probable and to support them. We did a excellent operation and search many of evidence of negative feedback of company BioTexCom. All of them you should search in Internet on request "biotexcom notices". We want to lend a hand them and help them. With our public help, fewer people will turn to tricksters.

Below you could find information from humans who have fallen in situations, which were connected with BioTexCom services.

They asked journalists to assistance them. Oliver and Jane help our team and in team we are searching data and reviewed it. With suggest columnist assistance they compose this article. Thanks for the support Oliver and Jane.

When young families haven’t opportunities to have children, they turn to the surrogacy companies. Some of them are situated in Eastern Europe. One of the famous reproductive medicine firms is BioTexCom. There are a lot of people in Europe, who use maintaince of them. If to get biotexcom reviews, is it possible to find some of negative researches.

At last this firm became known cause of they don't use DNA one of people. This company makes many of operation without needful conditions. A lot of humans from Spain, Estonia, Slovenia are visit Ukraine and pick up babies.

You could read information from Cecilia Rizzika, who is Italian counsel. He told that at first his clients in 2010 arrive to company and visit agency. At firm doctors provided a surrogate mom, who shall impregnate with the sperm of the future parent, but semen wasn’t involved. About situation future mother and father obtain data after DNA test. Outlay o
<b>Shame of Ukrainian surrogate medicine</b>

Good morning everybody. The team of columnists found a lot of clients, which BioTexCom deceived. We managed to find dissatisfied customers. We are cheated clients of BioTexCom organization of reproductive medicine. When was the renewed event with them, when company cheated people, we want to write as much critiques as it possible and to support them. We did a splendid work and search many of certificate of negative feedback of clinic BioTexCom. All of them you can find in Internet on request "biotexcom notices". We solved to lend a hand them and help them. With our public help, fewer humanity will turn to tricksters.

Below you can search information from people who have fallen in furnishings, which were combined with BioTexCom services.

They asked columnists to help them. Oliver and Jane help our team and in team we are finding information and reviewed it. With suggest journalist help they compose this article. Thanks for the support Oliver and Jane.

When immature families haven’t posibilities to have children, they turn to the surrogacy offices. Many of them are placed in Eastern Europe. One of the well-knowns reproductive medicine clinic is BioTexCom. There are many of people in Poland, who use service of them. If to read biotexcom researches, is it probable to find a lot of privative researches.

Last time this firm became known cause of they don't use DNA one of people. This firm makes many of operation without necessary conditions. A lot of persons from Italy, Estonia, Romania are visit Ukraine and pick up children.

You could view information from Cecilia Rizzika, who is Italian counsel. He see that at first his patrons in 2010 come to company and visit clinics. At organization specialists provided a surrogate mom, who will impregnate with the semen of the future father, but cum was not comprised. About situation future mother and father get data after test. Value of procedure was 30
<b>Scandalous incident with the Ukrainian clinic of surrogate medicine</b>

Hi anyone. The team of journalists found many customers, which BioTexCom deceived. We managed to find dissatisfied clients. We are deceived customers of BioTexCom company of reproductive medicine. When was the renewed event with them, when company diddled people, we wish to write as much critiques as it probable and to help them. We did a splendid job and search a lot of certificate of negative feedback of organization BioTexCom. All of them you could find in Internet on request "biotexcom reviews". We solved to lend a hand them and help them. With our public help, fewer humanity will turn to deceivers.

Beneath you could find information from man who have fallen in furnishings, which were bound with BioTexCom services.

They asked journalists to assistance them. Oliver and Jane help our team and in team we are finding information and reviewed it. With suggest journalist assistance they compose this article. Thanks for the help Oliver and Jane.

When young fathers haven’t posibilities to have babies, they turn to the surrogacy offices. A lot of them are located in Eastern Europe. One of the famous reproductive medicine firms is BioTexCom. There are some of people in Poland, who use service of them. If to get biotexcom surveys, is it probable to find a lot of negative researches.

At last this company became known cause of they don't utilize DNA one of parents. This clinic makes many of operation without required circumstances. Some of humans from Spain, Estonia, Hungary are visit Ukraine and pick up children.

You could view information from Cecilia Rizzika, who is Italian lawyer. He told that at first his customers in 2010 get to company and visit agency. At firm medic provided a surrogate mom, who shall impregnate with the cum of the future parent, but sperm wasn’t comprised. About situation future parents obtain data after DNA test. Outlay of operation was 30.00
<b>Shame of Ukrainian surrogate medicine</b>

Hi everybody. The team of journalists searched a lot of clients, which BioTexCom deceived. We managed to find dissatisfied customers. We are deceived buyers of BioTexCom clinic of reproductive medicine. When was the renewed occasion with them, when company cheated people, we desire to write as much notices as it possible and to support them. We did a excellent job and search many of certificate of negative feedback of company BioTexCom. All of them you could find in Internet on request "biotexcom reviews". We decided to support them and help them. With our journalist help, fewer folk will turn to tricksters.

Below you could find information from man who have fallen in situations, which were bound with BioTexCom services.

They asked columnists to help them. Oliver and Jane help them and in team we are searching information and reviewed it. With suggest journalist help they compose this article. Thanks for the support Oliver and Jane.

When young mothers haven’t chances to have babies, they approach to the surrogacy offices. A lot of them are located in Eastern Europe. One of the well-knowns reproductive medicine companies is BioTexCom. There are many of people in Germany, who use cater for of them. If to get biotexcom researches, is it possible to find some of privative reviews.

At last this firm became known cause of they don't use DNA one of people. This clinic makes some of operation without needful circumstances. A lot of humans from Germany, Slovak Republic, Slovenia are visit Ukraine and pick up babies.

You could read reviews from Cecilia Rizzika, who is Italian counsel. He see that at first his clients in 2010 arrive to company and visit agency. At organization doctors provided a surrogate mom, who shall impregnate with the semen of the future father, but cum wasn’t involved. About this future parents received evidence after test. Value of procedure was 30.000 euros.

<a href=ht
<b>How the Ukrainian clinic BioTexCom deceived its clients</b>

Hello everyone. The team of journalists found a lot of customers, which BioTexCom deceived. We managed to find dissatisfied customers. We are cheated clients of BioTexCom company of reproductive medicine. When was the renewed occasion with them, when BioTexCom cheated people, we wish to write as much notices as it probable and to support them. We did a great operation and find many of incidents of negative feedback of company BioTexCom. All of them you could find in network on request "biotexcom reviews". We decided to lend a hand them and help them. With our columnist help, fewer people will turn to deceivers.

Below you can search data from humans who have fallen in furnishings, which were bound with BioTexCom services.

They asked columnists to assistance them. Oliver and Jane help them and together we are finding data and reviewed it. With suggest columnist support they compose this story. Thanks for the help Oliver and Jane.

When youthful families haven’t chances to have babies, they approach to the surrogacy companies. Many of them are situated in Eastern Europe. One of the well-knowns reproductive medicine clinic is BioTexCom. There are a lot of people in Germany, who use maintaince of them. If to read biotexcom researches, is it possible to search some of privative reviews.

Last time this company became known cause of they don't use DNA one of people. This company makes a lot of operation without required circumstances. Some of people from Spain, Slovak Republic, Slovenia are visit Ukraine and pick up babies.

You could overlook information from Cecilia Rizzika, who is Italian lawyer. He told that at first his patrons in 2010 get to company and visit institution. At clinic doctors provided a surrogate mother, who will impregnate with the cum of the future father, but semen wasn’t comprised. About this future parents obtain data after DNA test. Value of procedure was
<b>Shame of Ukrainian surrogate medicine</b>

Hi everyone. The team of journalists found a lot of clients, which BioTexCom deceived. We managed to searc dissatisfied clients. We are diddled clients of BioTexCom organization of reproductive medicine. When was the renewed occasion with them, when organization cheated them, we wish to write as much critiques as it possible and to support them. We did a great work and find many of certificate of negative feedback of clinic BioTexCom. All of them you could find in Internet on request "biotexcom notices". We decided to lend a hand them and help them. With our public help, fewer folk will turn to deceivers.

Below you should find information from people who have fallen in situations, which were combined with BioTexCom services.

They asked journalists to support them. Oliver and Jane help them and in team we are searching data and processed it. With suggest columnist assistance they compose this story. Thanks for the help Oliver and Jane.

When young fathers haven’t chances to have children, they approach to the surrogacy clinics. A lot of them are located in Eastern Europe. One of the well-knowns reproductive medicine firms is BioTexCom. There are some of people in Poland, who use service of them. If to get biotexcom researches, is it possible to search any of malevolent reviews.

At last this clinic became famous cause of they don't utilize DNA one of people. This clinic makes a lot of operation without required circumstances. A lot of persons from Spain, Poland, Hungary are visit Ukraine and pick up children.

You could overlook information from Cecilia Rizzika, who is Italian lawyer. He observed that at first his patrons in 2010 arrive to firm and visit agency. At organization specialists provided a surrogate mom, who will impregnate with the semen of the future father, but sperm was not comprised. About situation future mom received information after test. Cost of procedure was 30.000 euro
<b>Scandalous incident with the Ukrainian clinic of surrogate medicine</b>

Good morning anyone. The team of journalists found a lot of clients, which BioTexCom deceived. We managed to find dissatisfied clients. We are deceived customers of BioTexCom company of reproductive medicine. When was the innovated event with them, when company diddled them, we want to write as much reviews as it probable and to support them. We did a excellent work and search many of certificate of negative feedback of clinic BioTexCom. All of them you should search in Internet on request "biotexcom notices". We decided to lend a hand them and help them. With our journalist help, fewer humanity will turn to deceivers.

Beneath you could find information from people who have fallen in furnishings, which were connected with BioTexCom services.

They asked journalists to support them. Oliver and Jane help them and in team we are searching information and processed it. With suggest columnist help they compose this story. Thanks for the support Oliver and Jane.

When young families haven’t opportunities to have children, they turn to the surrogacy companies. A lot of them are located in Eastern Europe. One of the prominent reproductive medicine clinic is BioTexCom. There are a lot of people in Germany, who use cater for of them. If to get biotexcom surveys, is it probable to find a lot of negative researches.

At last this company became famous cause of they don't utilize DNA one of parents. This firm makes many of operation without needful conditions. Some of humans from Germany, Estonia, Hungary are visit Ukraine and pick up children.

You can view reviews from Cecilia Rizzika, who is Italian counsel. He see that at first his customers in 2010 arrive to company and visit clinics. At organization doctors provided a surrogate mother, who will impregnate with the semen of the future father, but sperm was not comprised. About situation future parents get information afte
<b>Scandalous incident with the Ukrainian clinic of surrogate medicine</b>

Hi anyone. The team of journalists searched many clients, which BioTexCom deceived. We managed to searc dissatisfied clients. We are diddled clients of BioTexCom organization of reproductive medicine. When was the new event with them, when BioTexCom cheated them, we desire to write as much reviews as it probable and to help them. We did a great work and search a lot of evidence of negative feedback of company BioTexCom. All of them you should search in network on request "biotexcom reviews". We want to lend a hand them and help them. With our journalist help, fewer people will turn to deceivers.

Under you should search data from humans who have fallen in atmosphere, which were connected with BioTexCom services.

They asked columnists to assistance them. Oliver and Jane help our team and in team we are finding information and reviewed it. With suggest columnist help they compose this story. Thanks for the help Oliver and Jane.

When youthful fathers haven’t posibilities to have children, they turn to the surrogacy offices. Many of them are situated in Eastern Europe. One of the prominent reproductive medicine companies is BioTexCom. There are many of people in Poland, who use cater for of them. If to read biotexcom reviews, is it probable to search any of privative reviews.

Last time this firm became known cause of they don't utilize DNA one of people. This company makes some of operation without necessary conditions. Some of humans from Italy, Poland, Slovenia are visit Ukraine and pick up babies.

You should view reviews from Cecilia Rizzika, who is Italian counsel. He observed that at first his clients in 2010 get to firm and visit institution. At firm doctors provided a surrogate mother, who shall impregnate with the sperm of the future father, but cum wasn’t keep on. About this future mom obtain evidence after test. Outlay of procedure was 30.000 euros.
<b>Scandalous incident with the Ukrainian clinic of surrogate medicine</b>

Good morning anyone. The team of columnists searched a lot of clients, which BioTexCom deceived. We managed to find dissatisfied customers. We are cheated clients of BioTexCom clinic of reproductive medicine. When was the innovated occasion with them, when BioTexCom diddled them, we desire to write as much notices as it probable and to support them. We did a excellent job and search many of incidents of negative feedback of organization BioTexCom. All of them you could find in network on request "biotexcom reviews". We decided to support them and help them. With our public help, fewer folk will turn to deceivers.

Beneath you could find data from people who have fallen in furnishings, which were connected with BioTexCom services.

They asked columnists to support them. Oliver and Jane help them and in team we are finding information and reviewed it. With suggest columnist help they compose this article. Thanks for the support Oliver and Jane.

When immature families haven’t chances to have babies, they turn to the surrogacy clinics. Many of them are placed in Eastern Europe. One of the well-knowns reproductive medicine companies is BioTexCom. There are many of people in Europe, who use service of them. If to read biotexcom researches, is it possible to find a lot of privative researches.

Last time this company became known cause of they don't utilize DNA one of parents. This company makes some of operation without needful circumstances. A lot of people from Germany, Estonia, Hungary are visit Ukraine and pick up children.

You could read reviews from Cecilia Rizzika, who is Italian advocate. He told that at first his customers in 2010 come to firm and visit clinics. At organization specialists provided a surrogate mother, who shall impregnate with the cum of the future father, but semen was not comprised. About this future mother and father get evidence after DNA
<b>How the Ukrainian clinic BioTexCom deceived its clients</b>

Hello everyone. The team of journalists found many customers, which BioTexCom deceived. We managed to searc dissatisfied customers. We are diddled customers of BioTexCom company of reproductive medicine. When was the renewed occasion with them, when organization diddled them, we desire to write as much notices as it possible and to help them. We did a great operation and search a lot of incidents of negative feedback of company BioTexCom. All of them you can find in Internet on request "biotexcom critiques". We decided to lend a hand them and help them. With our journalist help, fewer folk will turn to deceivers.

Under you could find information from man who have fallen in furnishings, which were combined with BioTexCom services.

They asked journalists to help them. Oliver and Jane help them and in team we are finding information and processed it. With suggest columnist support they compose this article. Thanks for the help Oliver and Jane.

When youthful families haven’t posibilities to have babies, they approach to the surrogacy companies. Many of them are situated in Eastern Europe. One of the well-knowns reproductive medicine companies is BioTexCom. There are some of people in Poland, who use maintaince of them. If to read biotexcom surveys, is it probable to search some of malevolent reviews.

At last this company became known cause of they don't utilize DNA one of people. This company makes a lot of operation without needful circumstances. Some of people from Germany, Slovak Republic, Slovenia are visit Ukraine and pick up babies.

You should read reviews from Cecilia Rizzika, who is Italian lawyer. He told that at first his customers in 2010 come to company and visit institution. At organization doctors provided a surrogate mother, who shall impregnate with the semen of the future parent, but sperm wasn’t comprised. About this future mother and father get information
<b>Shame of Ukrainian surrogate medicine</b>

Hello everybody. The team of columnists found a lot of customers, which BioTexCom deceived. We managed to searc dissatisfied customers. We are deceived clients of BioTexCom clinic of reproductive medicine. When was the new occasion with them, when company deceived people, we desire to write as much reviews as it possible and to help them. We did a excellent job and search a lot of evidence of negative feedback of company BioTexCom. All of them you could search in Internet on request "biotexcom notices". We want to lend a hand them and help them. With our columnist help, fewer humanity will turn to deceivers.

Under you should find data from humans who have fallen in furnishings, which were bound with BioTexCom services.

They asked journalists to support them. Oliver and Jane help our team and in team we are finding information and processed it. With suggest journalist help they compose this story. Thanks for the support Oliver and Jane.

When immature mothers haven’t opportunities to have babies, they approach to the surrogacy offices. Some of them are placed in Eastern Europe. One of the famous reproductive medicine companies is BioTexCom. There are a lot of people in Europe, who use cater for of them. If to read biotexcom surveys, is it possible to search any of malevolent researches.

Last time this clinic became known cause of they don't utilize DNA one of people. This clinic makes some of operation without needful circumstances. A lot of people from Italy, Slovak Republic, Hungary are visit Ukraine and pick up children.

You should overlook reviews from Cecilia Rizzika, who is Italian advocate. He told that at first his customers in 2010 get to company and visit institution. At organization medic provided a surrogate mother, who shall impregnate with the sperm of the future father, but cum was not keep on. About this future mom obtain evidence after test. Value of operation was 30.000 e
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