• Quality Improvement in Health Care
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• v.18 no.1
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• pp.79-87
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• 2012

문제: 투약오류는 의료기관 전반에서 가장 많이 발생하는 오류의 하나이며, 환자에게 중대한 위해를 초래하기도 한다. 특히 고농축전해질은 문제발생의 가능성과 위험성이 높아 지속적인 관리 및 교육을 필요로 하고 있다. 목적: 발생한 투약오류 건에 대한 근본원인분석을 시행함으로써 유사사례가 발생하는 것을 예방하여 환자안전을 도모하고자 한다. 의료기관: 연세대학교 세브란스병원 질 향상 활동: 투약오류 건에 대해 근본원인분석 시행 후 고위험약물 관련 내규를 보완하였고, 고위험약물에 대한 Alert System 개발, 고위험약물 라벨 부착, 약 처방 관련 의료진 교육을 시행하였다. 개선효과: 고위험약물 투여와 관련된 시스템 개선 활동 이후 유사사례는 발생하지 않았고, 의료진 교육을 통하여 환자안전에 대한 인식과 중요성을 더욱 증가시켰다.

• Proceedings of the Korea Information Processing Society Conference
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• 2016.10a
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• pp.497-500
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• 2016

최근 임베디드 소프트웨어의 신뢰성과 안전성을 보장하기 위하여 코딩룰인 MISRA-C를 자동차 뿐만 아니라 군사, 의료 분야등 광범위한 분야에서 이용하고 있다. 하지만 MISRA-C가 자동차 시스템분야의 MISRA 가이드를 이용하여 개발되었기 때문에 타 분야의 분야별 특성을 모두 고려하지 못한다는 문제점이 제시되고 있다. 따라서 본 논문에서는 향후 의료기기 분야의 특성을 고려한 코딩룰을 제시하기에 앞서, 의료기기 소프트웨어에서의 코딩룰 필요성을 제시한다. 이를 위해 개발 단계의 의료기기 소스코드에 MISRA-C를 적용하여 정적 분석을 해보고, 적용 유무 따른 실행시간 오류 결과를 분석한다. 분석 결과, 코딩룰을 이용하면 실질적으로 실행시간 오류 발생을 막을 수 있고, 적용 과정에서 기타 다른 실행시간 오류들 또한 해결됨을 확인하였다. 위 결과로 본 논문에서는 의료 분야의 특성을 고려한 특화 코딩룰의 필요성을 제시한다.

• Journal of the Korean Society of Radiology
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• v.12 no.7
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• pp.919-927
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• 2018

The purpose of this study was to present simulation training model for general X-ray examinations and to analyze the errors that occur during the simulation training. From 2012 to 2018, a total of 183 students (77 men and 106 women) participated. The simulated X-ray system used computed radiography (CR) system. The contents of simulation training were patient's care, X-ray examinations accuracy, images stability, etc. As a result, it were found that the patient's position setting error, the accuracy error of the X-ray beam central ray, the image receptor's size and setting error, the error of the grid use, the marking error, and the error of X-ray exposure technical factors. It is expected that improved practical general X-ray examinations training of radiographer will be needed, focusing on these errors, so that we could contribute to the health care of the people by providing precise examinations and high quality medical service.

• Journal of Korean Academy of Nursing Administration
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• v.12 no.3
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• pp.397-405
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• 2006

Purpose: The purpose of this study was to develop the medical error reporting system and to validate an trait of error in the Operating Room. Methods: Descriptive research design was used. The subjects were 30 nurses with below 5-year-career in a University Hospital. Data was collected from 11, April until 22, April, 2005 using web-based error reporting system. Data was analyzed by mean, standard deviation, $X^{2}-test$ using SPSS WIN 10.0 program. Results: A time of medical error in operating room nursing frequent occurrence was from 12 pm. to 4pm. 'Lack of sterile materials' management' was the best frequent occurrence of medical error in operating room nursing. Conclusion: The findings of this study show that manager of healthcare organization must develop the error reporting system more familiar and ordinary. Afterward, we prevent the repetitive medical errors in nursing care through analyzing of error reporting system.

• Health Policy and Management
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• v.13 no.1
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• pp.116-132
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• 2003

본 논문에서는 시장에서 추계되는 소비자 의료가격지수의 바이어스를 가져오는 두 가지 원인을 살펴보았다 첫 번째로 가격지수구성이 갖는 구조적인 특성으로부더 야기되는 바이어스문제를 살펴보았고, 두 번째로, 소비자가 시장에서 실제로 구매하는 의료서비스와 해당 서비스 가격에 대한 모호한 정의로부터 야기되는 바이어스 문제를 살펴보았다 일반적인 가격지수는 최종 소비재 및 서비스 가격 변동 추계를 원칙으로 한다. 그러한 원칙이 의료가격 지수 구성의 경우 무시되고 의료서비스 생산을 위한 생산 요소가격 변동을 추계하여 최종 의료서비스 가격지수로 대용하고 있음을 보여주고 있다.

• Journal of the Korea Society for Simulation
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• v.26 no.3
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• pp.125-139
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• 2017

Recently, interest in improving the quality of EMS(emergency medical services) has been increasing. Much effort is being made to innovate the EMS process. The rapid progress of ICT technology has accelerated the automation or intelligence of EMS processes. This study suggests an emergency room management method based on real-time data considering resource utilization optimization, minimization of human error and enhancement of predictability of medical care. Emergency room operation indices - Emergency care index, Short stay index, Human error inducing index, Waiting patience index - are developed. And emergency room operation rules based on these indices are presented. Simulation was performed on a virtual emergency room to verify the effectiveness of the proposed operating rule. Simulation results showed excellent performance in terms of length of stay.

• The Journal of the Convergence on Culture Technology
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• v.4 no.2
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• pp.33-42
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• 2018

The Patient Safety Act was enacted on July 26, 2016. Patient safety law is a method to prevent harm by collecting and accumulating various errors through the reporting system. Therefore, in order for this law to be successfully implemented, it is necessary to vitalize 'the autonomous reporting and reporting learning system of patient safety accidents'. And In order for this system to be activated, a large amount of reporting data accumulation is a prerequisite. Nevertheless, there were only two reports in about 17 months. In this paper, I will criticize the validity of the current autonomous reporting system and the two proposed amendments, I would like to propose the introduction of a partial obligation reporting system.

• Korean Journal of Adult Nursing
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• v.25 no.6
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• pp.633-643
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• 2013

Purpose: The objective of this study was to identify the moderating and mediating effects of transformational-leadership in the relationship between medication error management climate and error reporting intention. Methods: Participants in this study were 118 nurses from 11 hospitals in Korea. The scales of medication error management climate, transformational-leadership and error reporting intention of nurses were used in this study. Descriptive statistics, t-test, ANOVA, partial Pearson correlation coefficient, and stepwise multiple regression were used for data analysis. Results: Higher transformational leadership group members had higher error management climate (t=3.88~4.64, p<.001) and higher intention to error reporting (t=2.49, p=.014). There were significant positive correlations between subcategories of medication error management climate and transformational leadership (r=.37~.51, p<.001). But error reporting intention was related to the transformational leadership (r=.28 p=.002), two subcategories such as 'learn from error' (r=.26, p=.004) and 'medication error competence' (r=.25, p=.008) of medication error management climate. Transformational-leadership was a moderator and a mediator between medication error management climate and error reporting intention. Conclusion: Based on the results of this study, transformational-leadership promotion training program to construct medication error management climate and to improve error reporting intention should be needed.

• Perspectives in Nursing Science
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• v.13 no.1
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• pp.1-9
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• 2016

Purpose: The purpose of this study was to identify the current state of research on healthcare professionals who make medical errors, who are known as "second victims", and support systems for them. Methods: An extensive search was conducted in electronic databases, Google, and websites related to patient safety using search terms such as "second victims", "medical errors", "adverse events", and "sentinel events". Results: Research to date in Korea has rarely focused on healthcare professionals' experiences after making medical errors. Abroad, there are comprehensive and systematic reviews of the impact of medical errors on healthcare professionals, their coping responses, and support systems for these second victims. Additionally, several institutes related to patient safety provide official guidelines and accessible support systems to support second victims in the aftermath of medical errors, especially serious adverse events. Conclusion: The impact of medical errors on healthcare professionals is profound and complex. Although systematic support systems for second victims are imperative, this has been overlooked in Korea. Thus, more research about the experiences of healthcare professionals after medical errors needs to be conducted prior to developing support systems or programs. Additionally, further efforts are required to raise awareness of the necessity of supporting healthcare professionals in healthcare systems.

• Proceedings of the Korean Operations and Management Science Society Conference
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• 2005.05a
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• pp.100-105
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• 2005

최근들어 RFID기술은 향후 바코드를 대체할 자동인식기술로 주목받고 있으며, 특히 유통물류분야의 응용이 기대되고 있다. 그러나 비용을 고려할 때 RF tag를 단품마다 적용하기에는 앞으로도 상당한 기간이 필요할 것으로 보인다. 오히려 인간의 생명과 안전을 다루는 의료분야에서 RFID를 사용하여 인간의 실수를 방지하는 응용시스템은 비용이 정당화되는 유용한 적용사례가 될 수 있다. 본 연구에서는 병원이나 약국의 처방약 조제과정에서의 인간의 오류를 방지할수 있는 RFID 응용시스템을 소개하고, 그 구조 및 개발사례를 소개한다.