• Title/Summary/Keyword: Patient Safety Accidents

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Falls in Patients of Medical Institutions in South Korea: A Literature Review

  • Jongwon Choi;Woochol Joseph Choi
    • Physical Therapy Korea
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    • v.30 no.1
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    • pp.1-7
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    • 2023
  • Background: Like many other countries, falls and related injuries in older adults are great concerns in South Korea. In particular, falls are common in medical institutions, often causing the increase of the length of hospitalization. Objects: The purpose of this review was to help understand and address falls in hospitalized individuals in South Korea. Methods: The review was conducted on literature published in Korean from 2010 to 2022, searched in the Korea Citation Index and PubMed. Keywords used for the search were as follows: falls, fall risk, fall risk assessment, hospital, inpatient, intervention, Korea, and prevention. Results: A total of 54 articles were found and reviewed. The most common place of fall accidents was the inpatient room, where there were many cases of falls while walking. Loss of balance was the most common cause of falls, and many falls occurred in patients admitted to the internal medicine. Furthermore, a risk of falling increased with the type of medications taken. In terms of tools to assess patients' fall risk, the Morse Fall Scale (MFS) was commonly used. Patient-specific fall prevention activities were common to address falls, and they decreased the frequency of falls and the fear of falling. Factors influencing the effectiveness of the fall prevention activities included attitudes toward falls, education, environmental factors, patient safety culture, and self-efficacy in preventing falls. Conclusion: Our results should help understand and address falls and injuries in medical institutions.

A Study on Failure Mode and Effect Analysis (FMEA) for Preoperative Risk Prevention (오류유형 영향분석(FMEA)을 적용한 수술준비 위험예방활동의 효과)

  • Kim, Chang Hee;Lee, Mi Hyang
    • Journal of Korean Academy of Nursing Administration
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    • v.22 no.5
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    • pp.415-423
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    • 2016
  • Purpose: The purpose of this research was to provide patients with safe preoperative preparatory procedures by removing any risk factors from the preparatory procedures by using failure mode and effects analysis, which is a prospective risk-managing tool. Methods: This was a research design in which before and after conditions of a single group were studied, Failure mode and effects analysis were applied for the preparatory procedures done before operations. Results: The preparation omission rate before the operation decreased from 2.70% to 0.04%, and operation cancellation rate decreased from 0.48% to 0.08%. Conclusion: Failure mode and effects analysis which remove any risk factors for patients in advance of the operation is effective in preventing any negligent accidents.

Evaluating the Usability of Medical Body Wrap in Whole Body Bone Scan (전신 뼈 검사에서 의료용 신체 고정구의 유용성 평가)

  • Dong-Oh Shim;Woo-Young Jung;Jae-Kwang Ryu;Cheol-Hong Park;Yoon-Jae Kim
    • The Korean Journal of Nuclear Medicine Technology
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    • v.28 no.1
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    • pp.49-56
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    • 2024
  • Purpose: When performing nuclear medicine examinations, body wraps or plastic supports are used to support and immobilize the patient's upper extremities to prevent patient safety accidents. However, the existing plastic supports compromised patient and staff safety, including finger entrapment and falls. Moreover, the body wrap provided by manufacturers compromised image quality such as upper extremities cutoff during whole body bone scan. Therefore, a new design of body wrap was developed to improve the issue, and this study aims to evaluate the usability of this medical body wrap. Materials and Methods: To evaluate the usability of the newly designed medical body wrap, a quality assessment of whole body bone scan images and a user satisfaction survey were conducted. Adult patients (male:female=129:152, age: 60.3±12.4 years, BMI: 24.0±4.2) aged 16 years or older who underwent a whole body bone scan during two periods: June to July 2022 (before improvement, n=139) and June to July 2023 (after improvement, n=142) were randomly selected for image quality evaluation. Five radiotechnologists visually evaluated the posterior view of the whole body bone image, including the left and right elbow (2 points), arm (2 points), whether the hand is extended (2 points), whether the hand is included (2 points), and the number of visible fingers (10 points), with a total of 18 points, which were converted to 100 points and analyzed for difference before and after improvement using an independent sample t-test. The user satisfaction questionnaire was evaluated using a 5-point Likert scale among 16 radiotechnologists from three general hospitals who experienced the new body wrap. Results: The image quality assessment was 82.0±13.8 before the improvement and 89.3±10.1 after the improvement, an average of 7.3 points higher, with a statistically significant difference (t=5.02, p<0.01). The user satisfaction survey showed an overall satisfaction rating of 4.1±0.8 for ease of use, 3.8±0.7 for scan preparation time, 3.9±0.7 for patient safety, 3.8±1.2 for scan accuracy, and 4.2±0.7 for recommendation (87.5% questionnaire response rate). Conclusion: The developed body wrap showed higher image quality and user satisfaction compared to the old method. Considering these results, it is deemed that the new body wrap may be more useful than existing methods.

A Study on Theory of Nurse Liability (간호사고의 원인과 그 예방)

  • Moon, Seong-Jea
    • The Korean Society of Law and Medicine
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    • v.5 no.1
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    • pp.622-660
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    • 2004
  • Medical services aren't done by doctors only but by different medical personnels. If any medical accident takes place, to what extent doctors, nurses and other personnels should respectively be liable for that should be determined. And when an employed doctor does any illegal medical act, his or her employer also should be responsible for that as a user. If a medical accident occurs, the victim or patient usually claims against the employer of the doctor sho causes the accident for compensation. And those who assist medical treatment, including nurses, should be liable for their own acts, but in case their doctor doesn't give any appropriate directions, the doctor should shoulder the liability. This indicates that nurses are also professional medical personnels, and that they should share the liability as well. There are lots of different medical personnels, but doctors and nurses are the pivot of team treatment, and nurses should also take responsibility for their services. Doctors and nurses are equal, as they are in pursuit of the same, namely, helping patients recover their health. Only their roles are different. If they respect each other and see each other as being responsible for their own roles, they will be able to consult together. Medical information on patients and nursing information should be shared by both of them, and patients should be provided accurate treatment and nursing services. If those who offer nursing services are unaware of required information due to conflicts with doctors, it might result in threatening the safety of patients. And in case any important information isn't properly conveyed between them, it might trigger a medical accident. Sophisticated and complex medical science requires medical personnels to be professional, and nurses as well as doctors need to be an expert. The fact treatment-related accidents take place often indicates that treatment is basically attended with danger. Furthermore, patients respond to all sorts of investigation and medicine in a different manner. They should be professional and knowledgeable to predict how they might respond and prevent any possible hazardous situations, and they are expected to have more knowledge in the future. Nonetheless, there aren't yet enough studies on the legal liability of nurses, and this study is expected to pave the way for future research on nurse liability against medical accidents.

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A Comparison of Interventions Recorded in Nursing Notes between Actue and Subacute Stage after a Cerebrovascular Accident (신경과 병동에 입원한 노졸중환자의 간호일지에 나타난 급성기와 아급성기의 간호중재 비교)

  • Choi, Ja-Yun;Park, Soon-Joo
    • Journal of Korean Academy of Nursing
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    • v.36 no.2
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    • pp.227-235
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    • 2006
  • Purpose: This study aimed to: 1) determine the core nursing interventions, and 2) compare acute interventions with subacute interventions recorded in the nursing notes of patients with cerebrovascular accidents (CVA). Methods: The nursing records covering the first 10 days of 30 patients with a CVA who were admitted from January to December 2004 at C University Hospital in Korea were examined. Data was collected using the nursing interventions classification (NIC) from January to April 2005. Finally, data analysis was carried out using mean, SD, and paired t-test according to domains, classes, and interventions. Results: The most frequent nursing intervention at both stage was 'Neurologic monitoring'. There were differences in interventions belonging to the 'Physiological: complex,' 'Behavioral,' 'Safety,' and 'Health system' domains between the acute and subacute stages. The frequency of interventions belonging to the 'Immobility management,' 'Neurological management,' 'Tissue perfusion management,' 'Patient education,' 'Risk management,' 'Health system mediation,' and 'Information management' classes at the acute stage was higher compared to the subacute stage. Conclusions: This study found out that nurses relatively recorded more nursing interventions during the acute stage hence the unsuccessful documentation of the subacute stage particularly in describing the specific nursing interventions at this stage.

A Study on the Development of Virtual Training System for Automated External Defibrillator (자동제세동기(AED) 가상훈련 시스템 개발에 관한 연구)

  • Song, Eun-Jee
    • Journal of the Korea Institute of Information and Communication Engineering
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    • v.21 no.7
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    • pp.1379-1385
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    • 2017
  • Virtual training is a kind of training that proceeds as if it were a real situation. In recent years, there has been a growing demand for experiencing a situation in which a virtual reality technology has not been experienced directly in the real world due to the rapid development of the technology. Especially, safety education is very necessary in Korea where safety accidents are caused by many disasters. Therefore, simulation of disaster response training using virtual reality is more urgent than ever. Although the automatic defibrillator is the medical device that is most needed to rescue patients with cardiac arrest, few people know how to use it. Therefore, there are very few cases where the use of automatic defibrillators has saved the patient's life in Korea. The proposed Automated External Defibrillator virtual training system enables immersive and experiential training in real situations and effective training at low cost.

Injury Analysis of a 12-passenger Van Rollover Accident (12인승 밴 전복사고의 상해 분석)

  • Kim, S.C.;Choi, H.Y.;Kim, B.W.;Park, G.J.;An, S.M.;Lee, K.H.
    • Journal of Auto-vehicle Safety Association
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    • v.10 no.1
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    • pp.20-26
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    • 2018
  • The fatality of rollover accidents in motor vehicle crashes is high despite their low incidence. Through the investigation of a 12-passenger van rollover accident in which 10 passengers were involved, we intend to analyze the correlation between the severity of the injury and the position of the occupants. We collected accident information from medical records, interviews, photo-images of the damaged van, field surveys, and the results of the Korean New Car Assessment Program (KNCAP). Based on the occupants' position, we classified injury sites and estimated injury severity. Passenger injury severity was evaluated by trauma score calculation. The initiation type of the rollover accident was passenger side 'fall-over' and the Collision Deformation Classification (CDC) code for the damaged van was 00TDZO3. The crash of the van involved 10 passengers, with an average age of $16.3{\pm}4.2years$. Few of the occupants had fastened seat belts at the time of the incident, and there was no airbag installed. One patient sustained severe liver injury and another was diagnosed with a fracture of the right humerus. The most common injuries were at the upper extremities and the neck. The average of Injury Severity Score (ISS) was $4.8{\pm}5.9$, and the average ISS of right-seated, mid-seated and left-seated occupants was $7.5{\pm}9.3$, $1.5{\pm}0.7$, and $3.3{\pm}2.1$ respectively (p>0.05). In the rollover (to-passenger side) accident of occupant unfastened, the average ISS of right-seated occupants (near side) was higher, but there was no statistically significant difference.

Infection Control in Parenteral Nutrition Preparation and Compounding (정맥영양의 조제와 감염관리)

  • Choe, Ji Hyeong;Baek, Jin Hee;Jo, Yun Hee;Cho, Yoon Sook
    • Journal of Clinical Nutrition
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    • v.10 no.2
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    • pp.31-37
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    • 2018
  • Recently, in Korea, the importance of preparation and use of injectable drugs has been emphasized due to successive fatal accidents caused by injection infections. Parenteral nutrition (PN) has also been identified as a cause of infection. Cases of infection due to PN have been reported not only in Korea, but also abroad, and contamination occurs mainly during the preparation of PN. Because sterile preparation and compounding of injections are very important for infection control and patient safety, this article reviews the major guidelines outlined thus far. The Korea Ministry of Food and Drug Safety in 2006 published guidelines and the KSHP (Korean Society of Health-System Pharmacists) recently issued guidelines for the aseptic preparation of injections. In addition, as US guidelines, the ASHP (American Society of Health-System Pharmacists) guidelines and United States Pharmacopeia (USP) <797> are also reviewed. The recent guidelines published by the KSHP have significance in that they were adopted in accordance with the domestic reality, even though they conform to foreign guidelines, and are expected to be guidelines for hospital pharmacists performing aseptic preparation work. In addition, the Korea Ministry of Health and Welfare is considering appropriate guidelines for the safe management of medications, training staff for infection prevention and strengthening staff capacity. Furthermore, the gradual expansion of aseptic compounding facilities and human resources, as well as the provision of adequate medical costs are also considered. Based on the establishment and standardization of injectable drugs compounding guidelines for Korean hospitals, it is believed that if human resources and facilities are supported and medical charges are improved, it will be possible to expect the safer preparation and use of injections.

Abdomino-perineal Organ Injuries Caused by Cultivators (경운기 사고에 의해 발생한 복부 및 회음부 장기 손상)

  • Yeo, Kwang Hee;Park, Chan Yong;Kim, Ho Hyun;Park, Soon Chang;Yeom, Seok Ran
    • Journal of Trauma and Injury
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    • v.28 no.2
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    • pp.60-66
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    • 2015
  • Purpose: Cultivator accidents are frequent and often lead to abdomino-perineal organ injury and, if severe, to death. This study presents the clinical characteristics, outcomes, and factors associated with mortality in patients who sustained an abdomino-perineal organ injury in cultivator accidents. Methods: We retrospectively analyzed the records of 53 patients who visited the emergency department of a tertiary hospital with abdomino-perineal organ injuries caused in cultivator accidents from April 2005 to March 2010. Results: All 53 patients had visited other medical institutions before visiting our hospital. Their mean age was $64.0{\pm}11.1$ (range, 20-80) years and 32 (60.4%) patients were 65 or older. The male-to-female ratio was 46:7. The chief complaint was abdominal pain (38 cases, 71.7%). The 53 patients included 41 cultivator operators (77.4%), 11 passengers (20.8%), and 1 passerby (1.9%). The causes of the injuries included a direct impact of the handlebar in 20 cases (37.7%), a rollover in 21 cases (39.6%), a fall in 10 cases (18.9%), and a wheel in two cases (3.8%). Several of the 53 patients had injuries to multiple abdomino-perineal organs, and the injured organs included the liver (23 cases, 26.4%), spleen (16 cases, 18.4%), pancreas (7 cases, 8.0%), small bowel (7 cases, 8.0%), mesentery (6 cases, 6.9%), adrenal gland (5 cases, 5.8%), and other organs. According to the abbreviated injury scale (AIS) dictionary, a thoracic injury was the most frequent co-injury (33 of 53 cases, 62.3%). Abdomino-perineal surgery was performed in 31 cases (58.8%) and angio-embolization was performed for six liver and two kidney injuries. Thirteen patients died (24.5%); all were males. The Injury Severity Scale (ISS) was lower in the survivors ($17.8{\pm}8.5$ vs. $27.0{\pm}16.0$; p=0.010). Conclusion: With the aging of agricultural workers, safety education programs should be implemented. Furthermore, the patient transfer system in agricultural areas must be improved.

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Analysis of Serious Game Elements of the Contents for Smart Device Based First-Aid Education (스마트 기기 기반 응급 처치 교육 콘텐츠의 기능성 게임 요소 분석 연구)

  • Suh, Dong-hee
    • Cartoon and Animation Studies
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    • s.47
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    • pp.273-294
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    • 2017
  • Korea has suffered numerous casualties due to a lot of accidents caused by safety insufficiency in recent years. Therefore, safety education is more important than ever before, and 'how to educate with what contents' is an important subject. Especially, experience education is effective rather than theoretical education because of the nature of safety education. However, it is not easy to design and develop these safety education programs. There is not much opportunity to access first-aid training, which is a part of safety education, unless it is compulsory to learn through public institutions. As a result, program utilization on safety education in Korea is still insufficient to what it should be. With that taken into account, this study proposed an effective serious game with fun and immersion for medical first-aid education. To do this, we analyzed five medical games through 20 cases of first-aid applications and elicited five factors that enhance the usability of serious games. With an analysis of five medical games, we selected one game to borrow the game rules, and applied the elicited five elements in the forms of level-up structure, iterative learning, compensation outcomes, competition system, and information transfer. The proposed medical education functional games should have 1) a character that plays a role of a patient, 2) a narrative flow that shows the situation, 3) the user should judge the situation and induce first aid. 4) compensation, levels, and simple repetition should be designed, and 5) information should be shared with the others in the given community. The results of this study is believed to contribute to enhance the medical emergency education in Korea.