• 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.

• Asian Pacific Journal of Cancer Prevention
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• v.17 no.5
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• pp.2611-2617
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• 2016

Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

• Korean Journal of Clinical Pharmacy
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• v.20 no.2
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• pp.120-127
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• 2010

Objective: The purpose of this study was to identify the type and frequency of chemotherapy-related prescribing errors and assess the pharmacist intervention in preventing potential harm. Methods: This study was performed in satellite pharmacy of oncology/hematology unit in tertiary teaching hospital from April to September, 2009. All chemotherapy prescribing errors detected by pharmacists were recorded. Frequency and characteristics of prescribing errors were analyzed. Pharmacists reviewed 28, 495 chemotherapy orders from 12,719 patients during 6-month periods. Results: A total of 835 prescription errors (2.93%) in 734 patients (5.77%) were detected by pharmacists. Alkylating agents (37.6%) followed by antimetabolite (23.35%), and mitotic inhibitors (21.44%) were the most prevalent classes in which errors occurs. The most common types of error detected were incorrect dose (34%), incorrect solution (33%), incorrect route (9%) and omission errors (8%). Changes in chemotherapy order due to pharmacists' intervention occurred in all error cases. Conclusion: Pharmacists' intervention in reviewing chemotherapy and drug orders intercepted potential harm due to prescribing errors. The current study provided strategies for reduction of medication errors.

• Asian Pacific Journal of Cancer Prevention
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• v.16 no.5
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• pp.1699-1705
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• 2015

Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

• Quality Improvement in Health Care
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• v.14 no.2
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• pp.125-132
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• 2008

Background : The number of outpatient injected anticancer drug is increasing. and the pathway of prescribing, compounding, and injecting anticancer drug is processed very rapidly in out-patient department. Moreover, Dose of anticancer drug is often changed depending on side effect of patients. So we need more effective inspection of anticancer drug prescriptions. The purpose of this study was to analyze the prescription errors for anticancer drugs in Out-Patient Department and to suggest system to prevent them. Method : The study took place at Asan Medical Center from July to September 2007. The pharmacists performed inspection of anticancer drug prescriptions before compounding and injecting. We used protocol-based anticancer drug order program and Electronic Medical Record (EMR). Result : During the study period, we analyzed 4683 prescriptions for out-patient. And we detected 55 medication errors (1.2%). Most common errors included dosage above or below the correct ones (56.3%), followed by incorrect treatment duration. Because most of dosing errors were in the range of usual dosage, it was hard to detect them. So when inspecting the prescription, we considered the medical records of individual patients. As a result, we could raise the efficiency of intervention. Therefore inspection using EMR could possibly reduce the number of anticancer drug errors. Conclusion : we are preventing the medication errors on stability and dosage above or below the maximum therapeutic dose according to the previous inspection system. However most of dosing errors were in the range of usual dosage according to the result of this study. Because of there was interpatient variability of dosage depending adverse effect. For improvement of quality assurance, we suggest inspection system based on patient's medical history.

• Korean Medical Education Review
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• v.21 no.1
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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.

• The Journal of KAIRB
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• v.5 no.2
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• pp.51-58
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• 2023

Purpose: To validate the effectiveness of obtaining consent education on errors in the consent process and to develop the education program for researchers. Methods: From February 2019 to February 2022, a 30-minute, 1:1 face-to-face consent education developed using the ADDIE model was conducted on 78 nurses as principal investigators. An informed consent audit tool, which includes 6 items developed by Asan Medical Center Human Research Protection Center, was used to analyze errors in obtaining informed consent process. Data analysis was performed using the SPSS ver. 25.0, and the Mann-Whitney U-test and χ²-test were utilized to verify the difference in errors between the experimental and control groups. Results: The participants consisted of 42 in the experimental group and 36 in the control group, with no statistically significant difference between the 2 groups. Both 2 groups showed the highest frequency of documentation errors, followed by format errors, errors related to a suitability of investigator, participant, or participant's legally acceptable representative, witness and confidentiality issues. After education, there was a significant decrease in both format errors (p=0.002) and documentation errors (p<0.001) in the experimental group. The proportion of participants without any errors in all items was higher in the experimental group (35.7%) compared to the control group (5.6%), and this difference was statistically significant (p=0.001). Conclusion: The obtaining consent education program was found to be effective in reducing informed consent errors. This study emphasizes the importance of education, suggesting the need for its expansion and accessibility, as well as the necessity for all researchers conducting clinical studies to receive the obtaining consent education.

• English Language & Literature Teaching
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• v.13 no.1
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• pp.47-66
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• 2007

Error analysis plays an important role because understanding the types of errors can give a better opportunity for both teachers and learners to recognize the nature of errors and ways of preventing them. This study looks into errors in the medical research abstracts written by 26 Koreans and also examines hedging expressions since hedging can be a necessary tactic in which the validity and objectivity of their claims is conveyed. The hedging expressions of these research abstracts are to be compared with those of Hyland (1996)'s study done on ENL academic writers of cell and molecular biology. The results of the study reveal that wrong word choice was the most commonly occurred errors, followed by prepositions, articles, adding and missing words. Many of these errors, except articles, seemed to derive from the native language interference. There were also run-on sentences, subject & verb agreement, tense, word order and minor errors. As for hedging, ESL medical writers seemed to use very limited hedging expressions and inappropriately strong modals. It is recommended to take variations of hedges using epistemic adverbials and adjectives to present their claims in a more valid and polite way. Limited verb choice was also noted. As for preventing or minimizing similar future errors, collocation practices in ESP focused on commonly used medical related words and expressions can be effective.

• Safety and Health at Work
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• v.9 no.4
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• pp.447-453
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• 2018

Background: Patient safety and accurate implementation of medication orders are among the essential requirements of par nursing profession. In this regard, it is necessary to determine and prevent factors influencing medications errors. Although many studies have investigated this issue, the effects of psychosocial factors have not been examined thoroughly. Methods: The present study aimed at investigating the impact of psychosocial factors on nurses' medication errors by evaluating the balance between effort and reward. This cross-sectional descriptive study was conducted in public hospitals of Tehran in 2015. The population of this work consisted of 379 nurses. A multisection questionnaire was used for data collection. Results: In this research, 29% of participating nurses reported medication errors in 2015. Most frequent errors were related to wrong dosage, drug, and patient. There were significant relationships between medications errors and the stress of imbalance between effort and reward (p < 0.02) and job commitment and stress (p < 0.027). Conclusion: It seems that several factors play a role in the occurrence of medication errors, and psychosocial factors play a crucial and major role in this regard. Therefore, it is necessary to investigate these factors in more detail and take them into account in the hospital management.

• English Language & Literature Teaching
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• v.8 no.2
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• pp.55-69
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• 2003

The study was done to find out if there's any correlation between the results of the state-run college entrance examination called "suneung," or college scholastic ability test (CSAT) and the frequency of errors of the medical and nursing students. These two groups of students were subjects for the research. The study was based on the writing of fresh year students who were required to take four-credit-hour English course. These students' writing, particularly their self introduction, was analyzed to see if medical students (the high-scored) made fewer errors on the writing and nursing students (the medium-scored) made more critical errors or vice versa, and furthermore, if the results of the scores had any correlation on the critical errors in writing. The concern of the study was also to explain the attributable factors of the outcome if the high-scored of CSAT actually made fewer errors as well as the types of critical errors made and ways to minimize them.