• Title/Summary/Keyword: Incident Report System

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A Case Study on Workers' Compensation Approval for a Hospital Nurse's Suicide (병원 간호사 자살에 대한 산업재해 승인 사례연구)

  • Yi, Kyunghee;Choi, Seonim;Park, Bohyun
    • Korean Journal of Occupational Health Nursing
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    • v.28 no.4
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    • pp.271-284
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    • 2019
  • Purpose: This study aimed to examine the process from occurrence of a hospital nurse's suicide to workers' compensation approval, responses of the parties involved, issues debated during approval deliberations, and significant policy changes resulting from the incident. Methods: We conducted in-depth interviews with involved parties and collected various documents, including newspaper articles, forum proceedings, and the agency report on determination of workers' compensation. Content analysis was performed on the collected data. Results: A Joint Task Force continuously reported its progress and findings through mass media such as newspaper, radio, and TV. These activities exerted pressure on a government agency to conduct an occupational disease review and significantly impacted the workers' compensation approval. The agency recognized associations between the hospital's inadequate nurse training and the suicide but did not confirm the excessive overtime and workplace harassment experienced by the nurse as causes of the suicide. This case's media coverage and impact resulted in a law prohibiting workplace harassment and a hospital system dedicating at least one nurse to training activities. Conclusions: This incident had a significant social impact as the first case of workers' compensation approval for a hospital nurse's suicide. However, the case produced no structural changes in nurses' working conditions such as heavy workloads.

Study on the evaporation of high melting temperature metal by using the manufactured electron hem gun system (전자총 시스템 제작과 이를 이용한 고융점 금속 증발에 관한 연구)

  • 정의창;노시표;김철중
    • Journal of the Korean Vacuum Society
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    • v.12 no.1
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    • pp.1-6
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    • 2003
  • An axial electron beam gun system, which emits the electron beam power of 50 kW, has been manufactured. The electron beam gun consists of two parts. One is the electron beam generation part. including the filament, cathode, and anode. The maximum beam current is 2 A and the acceleration voltage is 25 kV. The other part includes the focusing-, deflection-, and scanning coils. The beam diameter and ham trajectory can be controlled by these coils. The characteristic of each part is measured ior the optimum condition of evaporation process. Moreover, Helmholtz coil is installed inside the vacuum chamber to adjust the incident angel of the beam to the melting surface for the maximum evaporation. We report on the evaporation rates for zirconium(Zr) and gadolinium(Gd) metals which have the high melting temperatures.

Perception of the Patient Safety Risk Factors and Safety Management by Nurses in Emergency Service, Hospitals (응급실 간호사의 환자안전 위험요인에 대한 위험성 인식과 안전 간호활동)

  • Yun, Jung MI;Park, Hyoung Sook
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.21 no.4
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    • pp.380-391
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    • 2014
  • Purpose: This was a descriptive research study to examine the patient safety risk factors and the level of safety management of nurses in emergency service, hospitals and to analyze the relationship between the two factors. Method: Data for analysis were collected from 232 nurses in emergency service, hospitals in Busan and Gyeongnam from July 30 to September 7, 2013. Data were analyzed using descriptive statistics, t-test, one-way ANOVA, and Pearson correlation coefficients. Results: Therapeutic agents showed the highest risk level. The prevention of transfusion errors showed the highest performance. As the nurses were working in regional emergency medical centers and received education more than 7 sessions on patient safety, they readily recognized the riskiness of the safety risk factors. In addition, as the nurses were older than 40, married, having more education about safety and understood the incident report registration system well, they performed safety management better. There were significant correlations between perception of the patient safety risk factors and performance for safety management. Conclusion: Nurses in emergency service, hospitals should try to improve safety management to reduce the risk factors shown to be higher based on the results and ensure the patient safety.

A study on the pedicatric accident (응급실 내원 아동에 대한 분석)

  • Son In-A
    • Journal of Korean Public Health Nursing
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    • v.14 no.2
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    • pp.332-341
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    • 2000
  • Children's accident is a largely preventable public health problem. Little is known. however, about population-based incident and outcome of pediatric accident. From 1997.9 through 1998,8. admission data from emergency center in I city were collected. 1418 patient from 0 through 13 years of age were selected. All children with unintensional accidental problems were identified through coded sheet which categorizes epidemiologic characteristics. The specific purposes of this study are analysis about the characteristics of pediatric accidents. And it aims to produce the basic data necessary for accident prevention policy development. The results of this study were as follows; 1. The number of male children$(62.6\%)$ were higher than female children$(37.4\%)$ 2. The age group from 1 to 3 years represents the highest proportion$(45.4\%)$ of every accidents except on traffic accident. 3. The highest proportion of accident were as follows occured during the June-August$(34\%)$, Sunday$(22.6\%)$, and 17-21 p.m. $(37.2\%)$ 4. The main causes of accident include general trauma$(70.9\%)$, environmental accident$(l6.8\%)$. and traffic accident$(l2.1\%)$, 5. Preschool age group represents more than half$(65.4\%)$ of traffic accident. 6. environmental injury includes burns $(46.6\%)$, foreign body$(43.6\%)$, exposure to poisonous materials$(6.3\%)$. and bite(3.3) This results could be used to develope prevention programs and assist in accident prevention system development. And also these data substantiate that accident prevention program decrease safety-related injury rate in preschool age group must be concentrated on enhancing access to a system to have a significant effect. Furthermore, it is necessary for accident prevention. So several suggestions are described here: 1. Development of parent's educational program for accident prevention and safety education should be done actively. 2. Home safety surveillance system should be initiated. 3. The initiation of children's accident report system could be contribute the analysis and the reduction of accident.

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Analysis of doctors' cognition of patient safety at general hospitals (일개 상급종합병원 의사들의 환자안전문화에 대한 인식 분석)

  • Yu, Eun-Yeong;Jung, Sang-Jin
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.13 no.6
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    • pp.2607-2616
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    • 2012
  • This study was designed to figure out patient safety culture of medical institutions and try to utilize the study results as basic data for analyzing doctor's awareness of patient safety culture. To this end, questionnaire survey was conducted from August 1st to September 5th, 2011, targeting doctors working at senior general hospitals located in G city, and 194 questionnaires were utilized for final analysis. The research results are as follows. First, there was a difference in awareness of deployment of staffs depending on gender, age, term of service in the hospital, contact with patients and working hours per week in relationship between subjects, wards and hospital safety culture, and organizational learning and teamwork in the ward turned out to be significant in accordance with working hours per week, and all sub-areas of the ward safety culture by departments. Second, feedback about the malpractice, communication, report on malpractice frequency and overall safety awareness were found to be significant by departments in relationship of subjects, medical incident reporting system, patient safety evaluation and overall level of consciousness, and the overall safety awareness showed significant results according to contact with patients and working hours per week. Third, there was a positive corelation in sub-areas of the ward and hospital safety culture awareness, overall recognition and patient safety evaluation, and a positive corelation with medical incident reporting system was found in all areas except for attitude of managers/immediate supervisors and that of hospital executives. Fourth, sub-areas of patient safety culture which has a effect on patient safety showed significant results in organizational learning, openness of communication, overall safety awareness, systematic cooperation between departments, feedback/communication and non-punitive response. In conclusion, to increase the level of the ward and hospital patient safety culture of doctors and implement medical incident reporting system faithfully, it is necessary to activate teamwork through organizational learning in the ward based on the adequate staffing and working hours, promote open communication between departments and provide feedback on medical malpractice, thereby establishing a cooperative system by departments and active support of hospital executives for patient safet.

Studies on the Establishment of Tolerance Level of Radioactive Compounds in Livestock Feeds (가축 사료 중 방사성 물질 허용 기준 설정에 관한 연구)

  • Lee, Wanno;Ji, Sang-Yun;Kim, Jin Kyu;Lee, Yun-Jong;Park, Jun Cheol;Moon, Hong Kil;Lee, Ju-Woon
    • Journal of Radiation Industry
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    • v.5 no.4
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    • pp.337-345
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    • 2011
  • In order to provide an effective preparedness for a nuclear or radiological emergency happening in the domestic or neighborhood countries and to solve the vague fear of the people for the ingestion of radioactive livestock products, the establishment of national guideline level for radionuclides in feed is urgently necessary. This is because it is important to secure the safety and to manage the crisis in the agricultural, fishery and food sector by performing the effective safety control during and after nuclear incident. This study was performed to investigate the report cases of international organizations and foreign countries to set up a domestic control standard for managing radioactive substances that may be contaminated in animal feeds due to the nuclear power plant incident. In addition, an attempt was made to provide a useful reference that can help prepare a domestic control standard, using a coefficient that can consider the transfer into livestock through the intake of radioactive contaminated animal feeds. The standard radioisotopes investigated were confined to radioactive cesium ($^{137+134}Cs$) and iodine ($^{131}I$). Guideline level for the radionuclides was calculated by using the transfer coefficient factor and the maximum daily intake of animal feed provided by IAEA. For example, the maximum daily intake of animal feed was set as $25kg\;d^{-1}$ for dairy cows, $10kg\;d^{-1}$ for beef cattle, $3.0kg\;d^{-1}$ for pigs and $0.15kg\;d^{-1}$ for chickens. The result values for radioactive cesium were calculated as $8,696Bq\;kg^{-1}$, $4,545Bq\;kg^{-1}$, $1,667Bq\;kg^{-1}$ and $2,469Bq\;kg^{-1}$, respectively. The results for radioactive iodine showed the ranges between $741Bq\;kg^{-1}$ and $76,628Bq\;kg^{-1}$. These data can be utilized as a scientific reference for the preparation of a crisis management manual for the emergency control due to nuclear power plant accident in Korea and neighboring country. These results will contribute to establish the safe feed management system at national level as manual for responding the radioactive exposure of agricultural products and animal feeds, which are currently not established.

CQI Action Team Approach to Prevent Pressure Sores in Intensive Care Unit of an Acute Hospital Korea (중환자의 욕창 예방 연구 : 욕창 예방 QI팀을 중심으로)

  • Kang, So Young;Choi, Eun-Kyung;Kim, Jin-Ju;Ju, Mi-Jung
    • Quality Improvement in Health Care
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    • v.4 no.1
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    • pp.50-63
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    • 1997
  • Background : A pressure sore was defined as any skin lesion caused by unrelieved pressure and resulting in damage to underlying tissue. The health care institutions in the United States were reported the incident rate of pressure sores ranging from 6 to 14 %. Intensive Care Unit needed highest quality of care has been found over 40% incidence rate of pressure sore. Also, Annual expenditures for the care of pressure sores in patients in the United States have been estimated to be $7.5 billion; furthermore, 50 percent more nursing time is required to care for patients with pressure sore in comparison to the time needed to implement preventive measures against pressure sore formation. However, In Korea, there were little reliable reports, or researches, about incidence rates of pressure sore in health care institution including intensive care unit and about the integrated approach like CQI action team for risk assessment, prevention and treatment of pressure ulcers. Therefore, this study was to develop pressure sore risk assessment tool and the protocol for prevention of pressure sore formation through CQI action team activities, to monitor incident rate of pressure sore and the length of sore formation for patients at high risk, and to approximately estimate nursing time for sore dressing during research period as the effect of CQI action team. Method : CQI action team in intensive care unit, launched since early 1996, reviewed the literature for the standardized risk assessment tool, developed the pressure sore assessment tool based on the Braden Scale, tested its validity, compared on statistics including incidence rate of pressure sore for patients at high risk. Throughout these activities, CQI action team was developed the protocol, called as St. Marys hospital Intensive Care Unit Pressure Sore Protocol, shifted the emphasis from wound treatment to wound prevention. After applied the protocol to patients at high risk, the incident rate and the period of prevention against pressure development were tested with those for patients who received care before implementation of protocol by Chi-square and Kaplan-Meier Method of Survival Analysis. Result : The CQI action team found that these was significant difference of in incidence rate of pressure sores between patients at high risk (control group) who received care before implementation of protocol and those (experimental group) who received it after implementation of protocol (p<.05). 25% possibility of pressure sore formation was shown for the patients with 6th hospital day in ICU in control group. In experimental group, the patients with 10th hospital day had 10% possibility of pressure sore. Therefore, there was significant difference(p<.05) in survival rate between two groups. Also, nursing time for dressing on pressure sore in experimental group was decreased as much as 50% of it in control group. Conclusion : The collaborative team effort led to reduced incidence, increased the length of prevention against pressure sore, and declined nursing care times for sore dressing. However, there have had several suggestions for future study. The preventive care system for pressure sore should be applied to patients at moderate, or low risk throughout continuous CQI team activities based on Bed Sore Indicator Fact Sheet. Hospital-wide supports, such as incentives, would be offered to participants for keeping strong commitment to CQI team. Also, Quality Information System monitoring incidents and estimating cost of poor quality, like workload (full time equivalence) or financial loss, regularly in a hospital has to be developed first for supporting CQI team activities as well as empowering hospital-wide QI implementation. Being several limitations, this study would be one of the report cards for the CQI team activities in intensive care unit of an acute hospital and a trial of quality improvement of health care in Korea.

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Applicable Focal Points of HFACS to Investigate Domestic Civil Unmanned Aerial Vehicle Accidents (국내 민간 무인항공기 사고조사 HFACS 적용중점)

  • Lee, Keon-Hee;Kim, Hyeon-Deok
    • Journal of Advanced Navigation Technology
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    • v.25 no.3
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    • pp.256-266
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    • 2021
  • Domestic and foreign studies point to human factors as the main cause of unmanned aerial vehicle accidents, and HFACS is introduced as a technique to effectively analyze these human factors. Until now, domestic and foreign cases of analyzing the human factors of unmanned aerial vehicle accidents using HFACS were mainly targeted by military unmanned aerial vehicles, which can be used as an objective cause identification and similar accident prevention tool. In particular, identifying the focus of HFACS application considering the performance and operation conditions of domestic civilian unmanned aerial vehicles is expected to greatly help identify the cause and prevent recurrence in the event of an accident. Based on HFACS version 7.0, this study analyzed the accident investigation report data conducted by Korea Aviation and Railway Accident Investigation Board to identify the focus of HFACS application that can be used for domestic civilian unmanned aircraft accident investigations.

Clinical nurses' experiences of workplace verbal violence: a phenomenological study (병원 내 언어폭력에 노출된 임상 간호사의 경험: 현상학적 연구)

  • Woo, Min Soo;Kim, Hyoung Suk;Kim, Jeung-Im
    • Women's Health Nursing
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    • v.28 no.2
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    • pp.154-164
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    • 2022
  • Purpose: This study aimed to describe clinical nurses' lived experiences of workplace verbal violence through qualitative research using descriptive phenomenology. Methods: Six female Korean nurses who had less than 5 years of clinical experience and had experienced verbal violence in the workplace within the past year participated in the study. Data were collected through one-on-one in-depth interviews with the participants and analyzed using Colaizzi's phenomenological method. Results: A total of 27 codes, eight themes, and four theme clusters were derived from the participants' statements. The four theme clusters of the clinical nurses' experiences of verbal violence in the workplace were as follows: "tip of the iceberg," "beyond me and my control," "fear and resignation," and "personal burden." The participants recognized that nurses experienced verbal violence daily, and that the causes of and responses to verbal violence were determined by external situational factors rather than nurses' individual problems. This suggests that nurses felt that they had no choice but to personally cope with verbal violence and bear the consequences due to systematic indifference and silence about verbal violence experienced by clinical nurses. Conclusion: The findings show that verbal violence was pervasive and unmerited, yet often endured at the cost of a personal burden to nurses. A clear definition of verbal violence and education for employees are needed, and a reporting system should be established to report all forms of violence regardless of the severity of the incident.

Text Mining Analysis Technique on ECDIS Accident Report (텍스트 마이닝 기법을 활용한 ECDIS 사고보고서 분석)

  • Lee, Jeong-Seok;Lee, Bo-Kyeong;Cho, Ik-Soon
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.25 no.4
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    • pp.405-412
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    • 2019
  • SOLAS requires that ECDIS be installed on ships of more than 500 gross tonnage engaged in international navigation until the first inspection arriving after July 1, 2018. Several accidents related to the use of ECDIS have occurred with its installation as a new major navigation instrument. The 12 incident reports issued by MAIB, BSU, BEAmer, DMAIB, and DSB were analyzed, and the cause of accident was determined to be related to the operation of the navigator and the ECDIS system. The text was analyzed using the R-program to quantitatively analyze words related to the cause of the accident. We used text mining techniques such as Wordcloud, Wordnetwork and Wordweight to represent the importance of words according to their frequency of derivation. Wordcloud uses the N-gram model as a way of expressing the frequency of used words in cloud form. As a result of the uni-gram analysis of the N-gram model, ECDIS words were obtained the most, and the bi-gram analysis results showed that the word "Safety Contour" was used most frequently. Based on the bi-gram analysis, the causative words are classified into the officer and the ECDIS system, and the related words are represented by Wordnetwork. Finally, the related words with the of icer and the ECDIS system were composed of word corpus, and Wordweight was applied to analyze the change in corpus frequency by year. As a result of analyzing the tendency of corpus variation with the trend line graph, more recently, the corpus of the officer has decreased, and conversely, the corpus of the ECDIS system is gradually increasing.