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Patient Safety Program and Safety Culture (투약간호 중심의 환자안전 프로그램 개발 및 평가)

  • Kim, Young-Mee;Kim, Se-Young;Kim, Min-Young;Kim, Ju-Hee;Lee, Suk-Kyoung;Jang, Mi-Kyung
    • Journal of Korean Academy of Nursing Administration
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    • v.16 no.4
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    • pp.455-465
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    • 2010
  • Purpose: To determine the impact of the Patient Safety Program on the safety culture of nursing department. Methods: Patient Safety Program focused on medication safety was launched by QI team and patient safety committee. Patient Safety Program was composed of the establishment of improved reporting system as s way to learn from error, 'Patient Safety Guard' movement, and continuous education for medication safety. With one group pretest-posttest design, nurses' perception of the safety culture were measured with self-administered questionnaire. Subjects were all nurses and managers in nursing department of a tertiary teaching hospital in Seoul. Collected data from survey was statistically analyzed using t-test. Results: Patient Safety Program had been continued for 20 months in participation of all nurses and managers. Safety culture was improved (pretest=2.84, posttest=2.90, p<.001; 4 point scale). Conclusions: This study indicates that there has been a statistically significant increase in the nurses' perception of safety culture. These findings suggest that Patient Safety Program had made great contribution toward system wide safety culture in the hospital. To improve safety culture, leadership supports and flexibility to apply tailored interventions to the hospital were required necessarily.

Analysis of Bridge Team's Technical Behavior Pattern Appearing in Williamson's Turn (윌리암슨 선회법에 나타난 선교팀의 기술적 행동유형의 분석)

  • Yun, Chong-gum;Park, Deuk-Jin;Yim, Jeong-Bin
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.24 no.6
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    • pp.701-708
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    • 2018
  • Human error is an important cause of maritime accidents and the identification of human error is fundamental to maritime-accident preventions. In particular, the pattern of technical behavior taken in the circumstance of bridge teams(navigator & helmsman) provides important information to identify human error. The purpose of this study is to identify and analyze technical behavior pattern of bridge teams using Williamson's turn for rescue of persons overboard. The focus of this study is to build and analyze a cognitive model of the human behavior factors of the bridge teams in the process of implementing the experiments. The experimental environment was constructed using a ship-handling simulator and conducted an experiment on participants from 24 bridge teams. As a result of the experiment, it was able to identify the behavior pattern of the ship's maneuvering and maintain trajectory using the rudder and engine. This study is expected to correct human error in the bridge teams application to the certification and training of seafarers.

A Study on the Safety Handling Method of KCG's Water Jet Propulsion Ship (해양경찰 Water Jet 추진함정의 안전 조함법 연구)

  • Yun, Chong-Gum;Pak, Chae-Hong;Park, Deuk-Jin;Jung, Cho-Yeong
    • Journal of Navigation and Port Research
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    • v.41 no.6
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    • pp.373-380
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    • 2017
  • Operational errors caused by human factors, which is the major cause of marine accidents, include lack of knowledge, misunderstanding knowledge, and inadequate procedures. Recently, the type of propulsion mounted on KCG cutters has been diversified. In particular, the water jet propulsion unit, which was mainly installed in small boats, have been gradually expanded to medium and large size Coast Guard cutters, reaching 50% of the total. Axes types are divided into 2 to 4, and the bucket types are divided into Double Reverse Bucket(DRB) and Single Reverse Bucket(SRB); in these, the backward and steering control methods are completely different. Diversification of these operating systems can increase factors causing human error by the ships' operators. However, there is a lack of research on the maneuvering methods, considering the inherent active characteristics of each type of water jet. In this paper, we analyze the sideway method suitable for the condition of Coast Guard Exclusive wharf without assistance, based on the astern performance of each type. Then, a ship handling simulator was used for the experiment; they compared and verified through interviews of captains.

A Study on the U.S. Maritime Education Methodology and Engagement Status for the Graduates from Maritime Colleges (미국의 해기사 교육제도와 취업현황에 관한 연구)

  • Kim, Seong-Kyu
    • Journal of the Korean Institute of Navigation
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    • v.25 no.2
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    • pp.149-158
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    • 2001
  • This paper presents the educational methodology shipboard training methods of Maritime Colleges in U.S.A. and the fields of engagement in business of the graduates from them. There are two Maritime Academies, i.e. U.S. Merchant Marine Academy (USMMA) and U.S. Coast Guard Academy, which are supported by federal government and six Maritime Colleges operated by each State. Maritime Administration (MARAD) in the Department of Transportation (DOT) supports the training of merchant marine officers and crew members with a focus on safety in U.S. waterborne commerce. The shipboard training methods are not unique, but have various process. One is continuous sea term training onboard during sophomore (100 days) and junior year (200 days) in case of USMMA, the other is summer sea term training onboard every three months during freshman, sophomore and junior years in case of SUNY Maritime College. They offer also one month ship simulator training ashore. The employment status for the 1999 year graduates from USMMA shows 43 percent in the field of maritime afloat, 34 percent of maritime ashore, 22 percent of active duty military and 1 percent of others.

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Study on Improvements to Domestic Marine HNS Training Curricula through a Case Analysis of Marine Chemical Incidents (해상화학사고 사례 분석을 통한 국내 해상HNS 교육과정 개선에 관한 연구)

  • Kim, Kwang-Soo
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.27 no.1
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    • pp.97-112
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    • 2021
  • This study introduces lessons learned from investigation and analysis of major domestic and overseas cases of marine chemical incidents involving hazardous and noxious substances (HNS) during maritime transportation by chemical tankers carrying petrochemical products in bulk. The study then suggests plans to improve domestic marine HNS training curricula based on these lessons. Lessons learned from six incident cases are classified into the following six categories: 1) incident-related information, 2) safety, 3) pollution, 4) response, 5) salvage and 6) others. Based on these six categories, it is suggested that the curriculum provided by the Marine Environment Research & Training Institute for marine pollution prevention managers aboard noxious liquid substance carriers should be changed from the existing two-day training of eight subjects (16 h) to a three-day training of sixteen subjects (24 h). In addition, it is proposed that the marine chemical incident response course of the Korea Coast Guard Academy should be changed from the existing five-day training of fifteen subjects (35 h) to a six-day training of thirty-two subjects (48 h). These results are expected to contribute to sharing experiences and lessons learned about response to marine chemical incidents and to be used as basic data for improving the education and training courses for response personnel in preparedness for marine HNS incidents.

Implementation of Total Quality Management, Lessons Learned

  • Haas, Thomas J.
    • Proceedings of KOSOMES biannual meeting
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    • 2000.05a
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    • pp.27-36
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    • 2000
  • Managing quality is nothing new, but it increasingly become more challenging. Demands form customers, flatter organizations, measuring and assessing outcomes, stiffer competition for resources, technology, environmental concerns and others, all have created changes in the workplace for which enhanced leadership is needed. TQM, CQI, TQL, (managing quality), other acronyms can be summarized as a means of moving an organization into the new millennium with a keen focus on people, service, efficiencies, effectiveness and excellence. It is not an accident. It is the result of a clear, well-directed strategically focused thinking. Attention to quality encourages individuals and teams throughout organizations to continually learn, think and contribute ideas on how to explore processes that affect them. The organization must change into a learning organization that seeks to continually improve its processes and services. This learning attitude requires a cultural shift from autocratic to more participatory leadership. This presentation will examine the principles and lessons learned form implementation of quality initiatives from different organizations. Many of the themes shared are independent of the source and, as such, may be helpful in validating what you are doing or give you ideas on leading and implementing change within your organizations.

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Vital Tooth Bleaching: The State of Art (생활치아 미백술)

  • Choi, Dong Hun
    • Journal of the Korean Academy of Esthetic Dentistry
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    • v.7 no.1
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    • pp.6-17
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    • 1998
  • Tooth bleaching was being done more than 100 years ago, but the standard for vital tooth bleaching for the last quarter century has been the use of hydrogen peroxide with heat or with a combination of heat and light. The major disadvantages of this process are high cost, unpredictability of results, and patient discomfort. In March, 1989, the dental world was introduced to a new vital tooth bleaching process by Haywood and Heymann in their article "Nightguard vital bleaching(NGVB)." Interestingly enough, this simple technique could have been developed years ago if we had known about the chemical effects of carbamide peroxide on tooth structure. NGVB has created a resurgence in the area of bleaching, primarily because of its relative ease of application, the safety of the materials used, low cost, and the high percentage of successful treatments. This article was to explain simply about all around NGVB(etiology of stains, bleaching chemicals and mechanisms, bleaching effectiveness, side effect, documentation, indications, treatment therapy, laboratory procedure, case reports)

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On Flow Charactistics around Special Rudders by PIV Measurement; Flapped and Water-blowing Rudder (PIV 계측에 의한 특수타 주위의 유동특성에 대하여; 플랩러더와 물분사러더)

  • Gim, Oxoc
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.23 no.2
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    • pp.200-207
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    • 2017
  • The purpose in having a control surface on ships is to control the motion of the ship. The control surface may be composed entirely of a single movable surface or of a combination of fixed and movable portions. A control surface has one sole function to perform in meeting its purpose, and that is to develop a control force in consequence of its orientation and movement relative to the water. The forces and moments generated as a result of this rotation and angle of attack then determine the manoeuvring characteristics of the ship. In this paper, two-dimensional flow characteristics of a flapped rudder and a water-blowing control rudder were accomplished respectively by PIV method in a circulating water channel. Model test has been carried out with different angles of attack of main foil (NACA 0012) and flap's deflection angles to predict the performance of the flapped rudder and the water-blowing control rudder. The 2-frame particle tracking method has been used to obtain the velocity distribution in the flow field. $Re{\fallingdotseq}3.0{\times}10^4$ has been used during the whole experiments and measured results have been compared with each other.

Comparison of Response Systems and Education Courses against HNS Spill Incidents between Land and Sea in Korea (국내 HNS 사고 대응체계 및 교육과정에 관한 육상과 해상의 비교)

  • Kim, Kwang-Soo;Gang, Jin Hee;Lee, Moonjin
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.21 no.6
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    • pp.662-671
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    • 2015
  • As the type of Hazardous and Noxious Substances(HNS) becomes various and the transport volume of HNS increases, HNS spill incidents occur frequently on land and the sea. In view of various damages to human lives and properties by HNS spills, it is necessary to educate and train professional personnel in preparation for and response to potential HNS spills. This study shows the current state of response systems and education courses against HNS spill incidents on land and the sea to compare those with each other between land and sea in Korea. Incident command system on land are basically similar to that at sea, but leading authority which is responsible for combating HNS spills at sea is changeable depending on the location of HNS spill, as it were, Korea Coast Guard(KCG) is responsible for urgent response to HNS spill at sea, while municipalities are responsible for the response to HNS drifted ashore. Education courses for HNS responders on land are established at National Fire Service Academy(NFSA), National Institute of Chemical Safety(NICS), etc., and are diverse. Education and training courses for HNS responder at sea are established at Korea Coast Guard Academy(KCGA) and Marine Environment Research & Training Institute(MERTI), and are comparatively simple. Education courses for dangerous cargo handlers who work in port where land is linked to the sea are established at Korea Maritime Dangerous Goods Inspection & Research Institute(KOMDI), Korea Port Training Institute(KPTI) and Korea Institute of Maritime and Fisheries Technology(KIMFT). Through the comparison of education courses for HNS responders between land and sea, some recommendations such as extension of education targets, division of an existing integrated HNS course into two courses composed of operational level and manager level with respective refresh course, on-line cyber course and joint inter-educational institute course in cooperation with other relevant institutes are proposed for the improvement in education courses of KCG and KOEM(Korea Marine Environment Management Corporation) to educate and train professionals for combating HNS spills at sea in Korea.