Abstract
We studied human error in incidents related to the characteristics of action of medical technologists by duality analysis. The number of human-error-related incidents was 348 within nine years (2004–2012). The causes were absence of confirmation, mistaken idea, and wrong judgement made by self, among which the most important cause is absence of confirmation. By duality analysis, we can classify the incidents related to the characteristics of action of medical technologists on duty into five groups. The group with the most number of problems is composed of medical technologists with long experience and who have shown quality work. However, they are very important workers in the laboratory. To minimize the causes of such incidents, we suggest that they keep a record of their work, and technical management should be practiced daily. Therefore, reeducation on confirmation procedures and improvement of work amount are needed immediately.
