• Title/Summary/Keyword: Medical errors

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Analysis of Medical Errors in Operating Room Nursing using Web;based Error Reporting System (수술 간호업무 중 발생한 의료오류의 분석;웹기반 보고체계를 적용하여)

  • Kim, Myoung-Soo
    • 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.

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Patient Safety Education for Medical Students: Global Trends and Korea's Status (의과대학생을 위한 환자안전 교육의 국제적 동향 및 국내 현황)

  • Roh, HyeRin
    • Korean Medical Education Review
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    • v.21 no.1
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    • pp.1-12
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    • 2019
  • This study is a narrative review introducing global trends in patient safety education within medical schools and exploring the status of Korean education. Core competences for patient safety include patient centeredness, teamwork, evidence- and information-based practice, quality improvement, addressing medical errors, managing human factors and system complexity, and patient safety knowledge and responsibility. According to a Korean report addressing the role of doctors, patient safety was described as a subcategory of clinical care. Doctors' roles in patient safety included taking precautions, educating patients about the side effects of drugs, and implementing rapid treatment and appropriate follow-up when patient safety is compromised. The Korean Association of Medical Colleges suggested patient safety competence as one of eight essential human and society-centered learning outcomes. They included appropriate attitude and knowledge, human factors, a systematic approach, teamwork skills, engaging with patients and carers, and dealing with common errors. Four Korean medical schools reported integration of a patient safety course in their preclinical curriculum. Studies have shown that students experience difficulty in reporting medical errors because of hierarchical culture. It seems that patient safety is considered in a narrow sense and its education is limited in Korea. Patient safety is not a topic for dealing with only adverse events, but a science to prevent and detect early system failure. Patient safety emphasizes patient perspectives, so it has a different paradigm of medical ethics and professionalism, which have doctor-centered perspectives. Medical educators in Korea should understand patient safety concepts to implement patient safety curriculum. Further research should be done on communication in hierarchical culture and patient safety education during clerkship.

A Study on Translation of "Kumryosocho(金蓼小抄)" ("열하일기(熱河日記)" 소재(所載) "금료소초(金蓼小抄)" 번역(飜譯)에 관한 연구(硏究))

  • Park, Sang-Young;Kwon, Oh-Min;Oh, Jun-Ho
    • Journal of Korean Medical classics
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    • v.25 no.1
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    • pp.51-68
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    • 2012
  • Objective : This paper is aimed at suggesting further tasks by checking and rectifying the errors of the ancieut Chinese-vernacular Korean translations of Park Ji-won(朴趾源)'s "Kumryosocho". Method : In order to correct the wrongly transcribed "Kumryosocho" was contrasted with the original "Xiangzubiji(香祖筆記)", of which the part is "Kumryosocho". And then the errors and mistakes are discovered in published ancient Chinese-to-vernacular Korean translations. Result : In the course of checking the existing translations of "Kumryosocho", this paper identified the following types of errors. 1. Errors attributable to unfamiliar names of medicinal herbs 2. Errors due to the unfamiliarity with the names of diseases or symptoms in Traditional Koreau Medicine(TKM). 3. Errors committed in hand transcription. These types of errors were committed as well in translating jargons routinely used in TKM books. To the surprise, the errors above have been repeated even in the latest version of its translation. This means that the medicine-related materials by Silhak scholars, including "Kumryosocho", were placed at a dead zone of the research between Chinese classic scholars and TKM scholars. Conclusion : To minimize errors and mistakes, it is needed to activate the cooperative work of heterogeneous experts in two academic fields.

SPEECH-LANGUAGE EVALUATION BEFORE AND AFTER PHARYNGOPLASTY (인두피판성형술 전후의 언어 평가)

  • Yoo Yang-Keun;Han Jin-Soon;Kim Jung-Lock;Hwang Soon-Jung
    • Korean Journal of Cleft Lip And Palate
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    • v.3 no.2
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    • pp.61-66
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    • 2000
  • General characteristics of speech in deft palate patients are hypemasality and articulation disorder, which are affected by velopharyngeal inadequacy(VPI). 17 subjects with a chief complaint of 'nasal sounds and inaccurate pronunciation' underwent a speech-language evaluation before and after pharyngoplasty. Hypemasality and obligatory articulation errors were improved but compensatory articulation errors remained after pharyngoplasty. Above mentioned results indicate that resonance may be normal or improved following successful surgical management of VPI but, compensatory articulation errors will still persist. The separate recognition of hypemasality, compensatory and obligatory articulation errors in deft palate patients is important in determining the timing of therapy and selection of appropriate targets in therapy.

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Performance Estimation of an Implantable Epileptic Seizure Detector with a Low-power On-chip Oscillator

  • Kim, Sunhee;Choi, Yun Seo;Choi, Kanghyun;Lee, Jiseon;Lee, Byung-Uk;Lee, Hyang Woon;Lee, Seungjun
    • Journal of Biomedical Engineering Research
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    • v.36 no.5
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    • pp.169-176
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    • 2015
  • Implantable closed-loop epilepsy controllers require ideally both accurate epileptic seizure detection and low power consumption. On-chip oscillators can be used in implantable devices because they consume less power than other oscillators such as crystal oscillators. In this study, we investigated the tolerable error range of a lower power on-chip oscillator without losing the accuracy of seizure detection. We used 24 ictal and 14 interictal intracranial electroencephalographic segments recorded from epilepsy surgery patients. The performance variations with respect to oscillator frequency errors were estimated in terms of specificity, modified sensitivity, and detection timing difference of seizure onset using Generic Osorio Frei Algorithm. The frequency errors of on-chip oscillators were set at ${\pm}10%$ as the worst case. Our results showed that an oscillator error of ${\pm}10%$ affected both specificity and modified sensitivity by less than 3%. In addition, seizure onsets were detected with errors earlier or later than without errors and the average detection timing difference varied within less than 0.5 s range. The results suggest that on-chip oscillators could be useful for low-power implantable devices without error compensation circuitry requiring significant additional power. These findings could help the design of closed-loop systems with a seizure detector and automated stimulators for intractable epilepsy patients.

Experience and Perception on Patient Safety Culture of Employees in Hospitals (환자안전 문화에 대한 의료 종사자의 인식과 경험)

  • Kim, Eun-Kyung;Kim, Hui-Jeong;Kang, Min-Ah
    • Journal of Korean Academy of Nursing Administration
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    • v.13 no.3
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    • pp.321-334
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    • 2007
  • Purpose: The objectives of this study were to understand and compare perception and experience between clinical staffs(nurses and pharmacists) and Quality Improvement managers. Method: A qualitative study was conducted with 14 clinical staffs and QI managers who are working at tertiary hospitals in Korea. Interviews were recorded and transcribed for systematic analyses of qualitative data. Results: Most critically, while QI managers acknowledged that establishment of the patient safety culture and reduction of medical errors are urgent tasks for QI effort, clinical staffs don't seem to share such perceptions. All participants agree that staff shortage and no compliance to safety procedures were major reasons for medical error occurrences. Many suggested that an organizational culture where errors were perceived as a systematic problems rather than individual failures or carelessness should be formed to promote voluntary reporting of medical errors. Conclusion: A more systematic effort and attention at the hospital leadership and public policy level should be promoted to constitute societal consensus on the urgence of promoting patient safety culture and more specific approaches to tackle the patient safety problems.

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The improvement of exactitude of stereotactic surgery based on personal computer (개인용 컴퓨터를 이용한 뇌정위 수술의 정확도의 개선)

  • Kim, J.S.;Park, H.S.;Choi, K.H.;Chae, E.B.;Lee, Y.H.;Kim, S.I.
    • Proceedings of the KOSOMBE Conference
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    • v.1996 no.05
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    • pp.275-278
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    • 1996
  • Accuracy and reproducibility of coordinates, angles/areas and volume measurements are the mai goal of imaging-guided stereotactic systems. Errors in measurements are due to pitfalls in a present systems. Factors responsible for inaccuracy and variability on measurements are inappropriate display window settings, unequal spatial resolution, display/film distortion, inappropriate slice width, lack of isocentricity between gantry and frame, and nonparallelism between frame and scanning plan. The most important factor responsible for errors when using stereotactic frames is the nonparallel relationship to the plane of scanning. For the solution of above problem, author developed a computer program for the measurement of the coordinates of intracerebral target, which is operated using the personal computer. This program can calculate the actual spatial coordinates regardless of the inappropriate parallelism between frame and scanning plane and decrease the range of errors of measurements.

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Relationships among Non-Nursing Tasks, Nursing Care Left Undone, Nurse Outcomes and Medical Errors in Integrated Nursing Care Wards in Small and Medium-Sized General Hospitals (중소종합병원 간호·간병통합서비스 병동 간호사의 비간호 업무, 미완료 간호와 간호사 결과, 의료오류 간의 관계)

  • Park, Ju-Young;Hwang, Jee-In
    • Journal of Korean Academy of Nursing
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    • v.51 no.1
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    • pp.27-39
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    • 2021
  • Purpose: This study aimed to identify the degree of non-nursing tasks and nursing care left undone in integrated nursing care wards, and examine their relationships with nurses' burnout, job satisfaction, turnover intentions, and medical errors. Methods: A cross-sectional questionnaire survey was conducted. Data were collected using self-report questionnaires from 346 nurses working in 20 wards of seven small and medium-sized general hospitals, and analyzed using multiple regression and multiple logistic regression analysis with the SPSS WIN 25.0 program. Results: The mean score for non-nursing tasks was 7.32±1.71, and that for nursing care left undone was 4.42 ± 3.67. An increase in non-nursing tasks (β = .12, p = .021) and nursing care left undone (β = .18, p < .001) led to an increase in nurses' burnout (F = 6.26, p < .001). As nursing care left undone (β = .13, p = .018) increased, their turnover intentions also (F = 3.96, p < .001) increased, and more medical errors occurred (odds ratio 1.08, 95% confidence interval 1.02~1.15). Conclusion: Non-nursing tasks and nursing care left undone are positively associated with nurses' burnout, turnover intentions, and the occurrence of medical errors. Therefore, it is important to reduce non-nursing tasks and nursing care left undone in order to deliver high quality nursing care and in turn increase patient safety.

Evaluation of Physicians' Perception of Patient Safety Incidents Including Disclosure Utilizing Hypothetical Clinical Vignettes

  • Kim, Juyoung;Pyo, Jee-Hee;Choi, Eun-Young;Lee, Won;Jang, Seung-Gyeong;Ock, Min-Su;Lee, Sang-Il
    • Quality Improvement in Health Care
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    • v.28 no.1
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    • pp.34-44
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    • 2022
  • Purpose:We investigated physicians' responses to a series of clinical vignettes consisting of patient safety incidents, with and without disclosure of patient safety incidents (DPSI). Methods: An anonymous survey was conducted to investigate physicians' responses to the DPSI via online communities of physicians, and additional participants were recruited using a snowballing sampling method. We evaluated physicians' responses to the DPSI using eight hypothetical scenarios (HS) from the following perspectives: thoughts regarding medical errors, revisiting the physician, recommendation, lawsuit, criminal prosecution, trust score, and compensation amounts. We used the chi-square test to evaluate the overall differences in response rates among the scenarios. Statistical analyses were performed using the Student's t-test to compare the trust scores and compensation amounts. Results: A total of 910 physicians participated in this survey. An overall comparison of trust scores among HS showed that HS 1 (unclear medical errors, minor harm, and DPSI) had the highest trust score. In contrast, in the opposite scenario, HS 8 (clear medical errors, major harm, and DPSI not conducted) received the lowest scores. Cases with minor harm to patients (HS 1, 2, 5, and 6) showed lower compensation amounts than the others (HS 3, 4, 7, and 8). Physicians were more likely to think of situations with DPSI as not having medical errors (53.1% vs. 55.2%). In addition, the scenarios with DPSI were evaluated favorably in terms of intention to revisit, recommend, suit, and engage in criminal proceedings. Physicians showed higher trust scores (6.2 vs 5.4) and gave lower compensation amounts ($27.7 million vs $28.1 million), although there was no significant difference in terms of compensation amounts to the physician conducting DPSI. Conclusion: Our study showed overall positive perceptions regarding DPSI among Korean physicians.

Reducing Medical Errors : Patients' Self Protect Behaviors and Involvement in Decision Making (의료과오 감소를 위한 환자의 자기보호행동 및 의사결정 참여)

  • An Kyung-Eh;Kim Jeong-Eun;Kang Kim Min-Ah;Jung Yoen-Yi
    • Health Policy and Management
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    • v.16 no.3
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    • pp.70-85
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    • 2006
  • The purposes of this study were (1) to describe patients' behaviors to protect themselves from medical errors and their involvement in decision making on the diagnostic and treatment procedures (2) to examine whether patients' characteristics, such as age, sex, education, experience of hospitalization and/or surgery influence their self protect behaviors and involvement in decision making on the diagnostic and treatment procedures. A survey was conducted with 99 patients visited one university hospital in Seoul, Korea. A 20-item questionnaire, a 4-point Likert scale, was used to measure the degree of patients' active involvement in decision making; patients' self protect behaviors regarding medication, hospitalization, and surgery; and communication (Cronbach's alpha=0.801). SPSS 12.0 was used for the descriptive and correlation analysis. Only 6.1% of the participants were involved in the decision making process for the diagnostic tests and treatment. More patients did self-protect behaviors associated with the medication than other areas but widely varied from 18.2 to 94.3 % among various items. More people with age of 60 or older compared to people in younger age groups reported more protect behaviors particularly associated with medication. Patient education is needed to improve their active role in preventing medical errors and to promote patients' safety.