• 의학교육논단
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• 제21권1호
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• pp.13-21
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• 2019

Patient safety and medical errors have emerged as global concerns and error disclosure has been established as standards of practice in many countries. Disclosure of medical errors to patients and their families is an important part of patient-centred medical care and is essential to maintaining trust. However, physicians still hesitate to disclose errors to patients despite their belief that errors should be disclosed. Multiple barriers such as fear of medical lawsuits and punishment, fear of damaging their professional reputation, and diminished patient trust inhibit error disclosure. These barriers as well as lack of training or education programs addressing error disclosure contribute to a low estimated disclosure rate in real situations. Nowadays, the importance of patient safety education including error disclosure is emphasized and related research is increasing. In this paper, we will discuss the background of medical error disclosure and studies on education programs related to error disclosure. In this regard, we will examine the content and methods currently being taught, discuss the effects or outcomes of such education programs and obstacles or difficulties in implementing them. Finally, the direction of future error disclosure education, support systems, and education strategies will also be covered.

• 간호행정학회지
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• 제12권3호
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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.

• 한국인공지능학회지
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• 제5권1호
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• pp.1-9
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• 2017

Recently, the Q-Learning algorithm, which is one kind of reinforcement learning, is mainly used to implement artificial intelligence system in combination with deep learning. Many research is going on to improve the performance of Q-Learning. Therefore, purpose of theory try to improve the performance of Q-Learning algorithm. This Theory apply Cross Entropy Error to the loss function of Q-Learning algorithm. Since the mean squared error used in Q-Learning is difficult to measure the exact error rate, the Cross Entropy Error, known to be highly accurate, is applied to the loss function. Experimental results show that the success rate of the Mean Squared Error used in the existing reinforcement learning was about 12% and the Cross Entropy Error used in the deep learning was about 36%. The success rate was shown.

• 대한의용생체공학회:의공학회지
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• 제42권6호
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• pp.259-267
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• 2021

Recently, the market for personal health care and medical devices based on Bluetooth Low Energy(BLE) has grown rapidly. BLE is being used in various medical data communication devices based on low power consumption and universal compatibility. However, since data errors occurring in the transmission of medical data can lead to medical accidents, it is necessary to analyze the causes of errors and study methods to reduce data error. In this paper, the minimum communication speed to be used in medical devices was set to at least 800 byte/sec based on the wireless electrocardiography regulations of the Ministry of Food and Drug Safety. And the data loss rate was tested when data was transmitted at a speed higher than 800 byte/sec. The factors that cause communication data error were classified, and the relationship between each factor and the data error rate was analyzed through experiments. When there were two or more activated peripherals connected to the central, data error occurred due to channel hopping and bottleneck, and the data error rate increased in proportion to the communication distance and the number of activated peripherals. Through this experiment, when the BLE is used in a medical device that intermittently transmits biosignal data, the risk of a medical accident is predicted to be low if the number of peripherals is 3 or less. But, it was determined that BLE would not be suitable for the development of a biosignal measuring device that must be continuously transmitted in real time, such as an electrocardiogram.

• 품질경영학회지
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• 제38권4호
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• pp.491-503
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• 2010

This paper presents a research model, which identifies a relationship between medical error reduction, efficiency of organizational systems, and employee satisfaction with organizational support. The proposed model was tested through hypotheses, based on data collected from 210 respondents from the medical staff of large -sized (i.e., more than 500 beds) residential hospitals in cities of South Korea. The results of the study showed that medical error reduction is associated with corrective system and employee satisfaction with organizational support. Therefore, it is very important that organizations improve their employees' satisfaction by providing sufficient support (e.g., information support and sharing, work guide book, etc.) for their work. In addition, in organizational systems, the corrective system has positive relationship with medical error reduction. In terms of corrective procedures, leaders or managers can make improvements by providing and supporting a friendly work environment where errors may be reported without blame and discussed in order to be corrected.

• 한국의학물리학회:학술대회논문집
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• 한국의학물리학회 2002년도 Proceedings
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• pp.74-82
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• 2002

In Intensity Modulated Radiotherapy (IMRT), radiation is delivered in a multiple of Multileaf Collimator (MLC) subfields. A subfield with a small leaf-to-leaf opening is highly sensitive to a leaf-positional error. We introduce a method of identifying and rejecting IMRT plans that are highly sensitive to a systematic MLC gap error (sensitivity to possible random leaf-positional errors is not addressed here). There are two sources of a systematic MLC gap error: Centerline Mechanical Offset (CMO) and, in the case of a rounded end MLC, Radiation Field Offset (RFO). In IMRT planning system, using an incorrect value of RFO introduces a systematic error ΔRFO that results in all leaf-to-leaf gaps that are either too large or too small by (2ㆍΔRFO), whereas assuming that CMO is zero introduces systematic error ΔCMO that results in all gaps that are too large by ΔCMO = CMO. We introduce a concept of the Average Leaf Pair Opening (ALPO) that can be calculated from a dynamic MLC delivery file. We derive an analytic formula for a fractional average fluence error resulting from a systematic gap error of Δ$\chi$ and show that it is inversely proportional to ALPO; explicitly it is equal to, (equation omitted) in which $\varepsilon$ is generally of the order of 1 mm and Δx=2ㆍΔRFO+CMO. This analytic relationship is verified with independent numerical calculations.

• 한국의학물리학회지:의학물리
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• 제28권4호
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• pp.149-155
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• 2017

Radiotherapy patients should maintain their treatment position as patient setup is very important for accurate treatment. In this study, we evaluated patient setup error quantitatively according to Cone-Beam Computed Tomography (CBCT) Gamma Density Analysis using Mobius CBCT. The adjusted setup error to the $QUASAR^{TM}$ phantom was moved artificially in the superior and lateral direction, and then we acquired the CBCT image according to the phantom setup error. To analyze the treatment setup error quantitatively, we compared values suggested in the CBCT system with the Mobius CBCT. This allowed us to evaluate the setup error using CBCT Gamma Density Analysis by comparing the planning CT with the CBCT. In addition, we acquired the 3D-gamma density passing rate according to the gamma density criteria and phantom setup error. When the movement was adjusted to only the phantom body or 3 cm diameter target inserted in the phantom, the CBCT system had a difference of approximately 1 mm, while Mobius CBCT had a difference of under 0.5 mm compared to the real setup error. When the phantom body and target moved 20 mm in the Mobius CBCT, there are 17.9 mm and 13.5 mm differences in the lateral and superior directions, respectively. The CBCT gamma density passing rate was reduced according to the increase in setup error, and the gamma density criteria of 0.1 g/cc/3 mm has 10% lower passing rate than the other density criteria. Mobius CBCT had a 2 mm setup error compared with the actual setup error. However, the difference was greater than 10 mm when the phantom body moved 20 mm with the target. Therefore, we should pay close attention when the patient's anatomy changes.

• 한국의학물리학회:학술대회논문집
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• 한국의학물리학회 2006년도 제33회 추계학술대회 발표논문집
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• pp.109-109
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• 2006

• 한국의료질향상학회지
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• 제24권1호
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• pp.23-29
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• 2018

Background: The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Methods: Cross-sectional and self-administered questionnaire survey was conducted on 34 students from one medical school using a modified version of the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS). We assessed $4^{rd}-year$ medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. The overall response rate was 66.4%. Results: Among safety domains, "teamwork culture" was rated highest. "Error disclosure culture" received the lowest ratings. Regarding the error disclosure domain, only 10% of respondents reported that they have received education or training on how to disclose medical error to patients. Independent of survey domains, when students were asked "Overall, do you think your hospital is safe based on your clinical rotation?", 61.8% reported that the hospital was safe. Conclusions: Assessing students' perceptions of safety culture can provide clerkship directors and educators with information that enhances the educational environment and promotes patient safety. Discussions of medical errors, patient safety, and how best to incorporate an analysis of these issues into the existing curriculum are needed.

• 한국의료질향상학회지
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• 제18권1호
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• pp.57-70
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• 2012

Background : The purpose of this study was to understand healthcare workers' perception of patient safety culture and medical error reporting to provide basic resources for the settlement of patient safety culture in medical institutions in Korea. Methods : For this purpose, convenience sampling by self-selection was applied to healthcare workers at a university hospital in Gyeonggi-do and a total of 482 people responded. The survey used the translated version of AHRQ in Korean and distributed through the Intranet system of the hospital. Result : The ratio of positive response was low overall. Among the responses, the response for 'Nonpunitive Response to Error' was the lowest at 17.7%, followed by the responses for 'Staffing' at 21.3%, 'Handoffs & Transitions' at 32.9%, and 'Communication Openness' at 44.3%. In result of surveying whether the responders have reported patient safety incidents during the past 12 months, 68.3% responded 'not once.' Conclusion : The perception of healthcare workers' patient safety culture and medical error reporting, when compared to AHRQ, was lower overall. It is important for healthcare workers to pay greater attention to patient safety to create a safe hospital culture where they do not punish or criticize related individuals or departments.