• Title/Summary/Keyword: administration errors

Search Result 249, Processing Time 0.024 seconds

Analysis of the causes of high-risk intravenous medication errors recognized by hospital nurses (병원간호사가 인식한 고위험 정맥주사 투약오류 원인 분석)

  • Kim Mi Ran
    • The Journal of the Convergence on Culture Technology
    • /
    • v.10 no.3
    • /
    • pp.625-633
    • /
    • 2024
  • This study was attempted to identify the perception and experience of hospital nurses on medication errors of high-risk intravenous drugs, and to identify the causes of medication errors and ways to improve them. The subjects of the study were nurses with work experience related to high-risk intravenous administration working at a university hospital located in D City, and data were collected between May 16 ~ 30, 2021. As a result of the study, six key factors were identified as the key factors in the safety of high-risk intravenous injections: the lack of a protocol for the administration of major drugs in each ward, the lack of training in the operation of the injection machine, the lack of standardized procedures for administering high-risk intravenous injections, the lack of individualized medication training for nurses, the lack or lack of the hospital's own drug list, and the lack of identification of drugs packaged in similar containers. At the nursing practice level, it is proposed to apply a high-risk intravenous medication safety program and conduct a future study to identify safety outcome indicators.

Economic Selection of the Optimal Process Mean Using Sequential Inspection to Reduce the Effect of Measurement Errors (측정오차를 고려한 최적 공정평균의 경제적 설정 - 축차검사의 활용)

  • Park, Hwan-Su;Chang, Young-Soon
    • Journal of Korean Society for Quality Management
    • /
    • v.34 no.2
    • /
    • pp.12-21
    • /
    • 2006
  • This paper considers the problem of selecting the most profitable process mean for production processes where measurement errors exist in inspection systems. For such situations, a sequential inspection procedure is proposed to reduce measurement errors. The decision to accept, reject, or take an additional inspection of an item is made at every measurement point until the number of repeated measurements reaches its upper bound. An expected profit model is constructed and the optimal process mean, the cut-off values, and the upper bound of the number of repeated measurements are obtained when accepted(rejected) items are sold at regular(reduced) price. A numerical study is performed to investigate the performance of the proposed procedure.

Evaluation of the Bar Code Medication Administration and Blood Transfusion System in a Tertiary Hospital (투약.수혈 바코드 시스템 적용 평가)

  • Cho, Myung-Sook;Song, Mi-Ra;Jang, Mi-Ra
    • Journal of Korean Academy of Nursing Administration
    • /
    • v.18 no.1
    • /
    • pp.23-32
    • /
    • 2012
  • Purpose: The purpose of this study was to assess the clinical application of a bar code medication administration and blood transfusion system and to identify its effects from the aspect of patient safety and nurse satisfaction in a tertiary hospital. Methods: The system in this study was PDA with bar code reading capability and wireless networking function. The logs created during application of the system and administration error reports were analyzed. For nurses' satisfaction with the system, data were collected from 337 nurses using the instrument developed by Otieno et al. and analyzed using descriptive statistics. Results: The system application rate was 98.8%, and the main failure cases in the system application included bar code or network related factors. When the system was applied, 0.02% of errors were prevented. The nurses were satisfied with the system from the aspect of patient safety, however relatively less satisfied with the system from the aspect of work efficiency. Conclusion: The results of the study indicate the usefulness for patient safety of applying the bar code medication administration and blood transfusion system to clinical practice. However technological improvements including bar code and network communication are necessary to ensure higher work efficiency in nursing practice.

A Framework for Computerized Human Error Analysis System - Focused on the Railway Industry (철도사고 인적오류 분석을 위한 지원시스템 프레임웍 설계)

  • Shin, Min-Ju;Baek, Dong-Hyun;Kim, Dong-San;Yoon, Wan-Chul
    • Journal of the Ergonomics Society of Korea
    • /
    • v.27 no.3
    • /
    • pp.43-52
    • /
    • 2008
  • Human errors are now considered as the most significant source of accidents or incidents in large-scale systems such as aircraft, vessels, railway, and nuclear power plants. As 61% of the train accidents in Korea railway involving collisions, derailments and fires were caused by human errors, there is a strong need for a systematic research that can help to prevent human errors. Although domestic railway operating companies use a variety of methods for analyzing human errors, there is much room for improvement. Especially, because most of them are based on written papers, there is a definite need for a well-developed computerized system supporting human error analyzing tasks. The purpose of this study is to propose a framework for a computerized human error analysis system focused on the railway industry on the basis of human error analysis mechanism. The proposed framework consists of human error analysis (HEA) module, similar accident tracking (SAT) module, cause factor recommendation (CFR) module, cause factor management (CFM) module, and statistics (ST) module.

Study of Curriculum Construction and Changes in High School Textbook of the Fisheries Business Administration General (고등학교 수산경영일반 교과과정 구성과 변화에 대한 연구)

  • LEE, Dongho
    • Journal of Fisheries and Marine Sciences Education
    • /
    • v.27 no.5
    • /
    • pp.1343-1351
    • /
    • 2015
  • Though the history of fisheries business administration education has it's own uniqueness, the research or study of that still insufficient. And in spite of the structural shift of society and environmental diversity, there's few research that analyzing or examining the curricular constitution and change recently. The process of this research was implemented with investigating the objective and content domains concerning marine education in the fisheries and marine curriculum and changes of them. The changes of fisheries business administration education reviewed and analyzed in the view point of construction of the textbook, contents of the each changes and recency comparison of tables and figures of the high school textbook of the fisheries business administration general. The results show that most of the changes have been reflected by the demands of the society including fisheries related law, policy and distribution networks. But there are still some errors and necessity of improvements in data and descriptions. The results of this study would help develop sustainable curriculum design for further changes and give more effective guidelines for identifying the core of fisheries business administration education.

Evaluation of Short-Term Prediction Skill of East Asian Summer Atmospheric Rivers (동아시아 여름철 대기의 강 단기 예측성 검증)

  • Hyein Kim;Yeeun Kwon;Seung-Yoon Back;Jaeyoung Hwang;Seok-Woo Son;HyangSuk Park;Eun-Jeong Cha
    • Atmosphere
    • /
    • v.34 no.2
    • /
    • pp.83-95
    • /
    • 2024
  • Atmospheric rivers (ARs) are closely related to local precipitation which can be both beneficial and destructive. Although several studies have evaluated their predictability, there is a lack of studies on East Asian ARs. This study evaluates the prediction skill of East Asian ARs in the Korean Integrated Model (KIM) for 2020~2022 summer. The spatial distribution of AR frequency in KIM is qualitatively similar to the observation but overestimated. In particular, the model errors greatly increase along the boundary of the western North Pacific subtropical high as the forecast lead time increases. When the prediction skills are quantitatively verified by computing the Anomaly Correlation Coefficient and Mean Square Skill Score, the useful prediction skill of daily AR around the Korean Peninsula is found up to 5 days. Such prediction limit is primarily set by the wind field errors with a minor contribution of moisture distribution errors. This result suggests that the improved prediction of atmospheric circulation field can improve the prediction of East Asian summer ARs and the associated precipitation.

A comparison of neural networks to ols regression in process/quality control applications

  • Nam, Kyungdoo;Sanford, Clive C.;Jayakumar, Maliyakal D.
    • Korean Management Science Review
    • /
    • v.11 no.2
    • /
    • pp.133-146
    • /
    • 1994
  • This study compares the performance of neural networks and ordinary least squares regression with quality-control processes. We examine the applicability of neural networks because they do not require any assumptions regarding either the functional from of the underlying process or the distribution of errors. The coefficient of determination($R^2$), mean absolute deviation(MAD), and the mean squared error(MSE) metrics indicate that neural networks are a viable and can be a superior technique. We also demonstrate that an assessment of the magnitude of the neural notwork input layer cumulative weights can be used to determine the relative importance of predictor variables.

  • PDF

Enhancing Implementation Capability of National Maritime Administration for Preventing Marine Pollution (해양오염방지를 위한 행정역량 제고)

  • 이상집
    • Journal of the Korean Society of Marine Environment & Safety
    • /
    • v.1 no.2
    • /
    • pp.1-15
    • /
    • 1995
  • Almost of all impediments to enhancing ship safety and preventing vessel-source marine pollution arise from the interaction between direct and indirect factors. The direct factors come from human errors and failure in compliance with the international convention standards for the operation of cessel. The indirect factors derive from the will and attitudes of the countries taking little responsibilities with appropriate seriousness for policing their fleets. By focusing on these aspects, this paper reviews the effectiveness of existing countermasures adopted by IMO and intends to propose a new paradigm to improve the implementation capability of each nation by suggesting frameworks of maritime administration models.

  • PDF

Research on Continuous Improvement in Productivity for The Central and Local Government Administration (정부 및 지방행정혁신의 지속적 성과향상 방법 -조직개발과 업무혁신 변화관리 실행 매뉴얼 -)

  • Kim, Jin-Kyu;Shin, Dong-Ju;Kim, Hyoung-Ki
    • Journal of Digital Convergence
    • /
    • v.3 no.2
    • /
    • pp.39-57
    • /
    • 2005
  • This research is about continuous improvement in productivity for the central and local government administration. It is a comprehensive execution manual that summarizes from preparation to completion of this task. If you follow the process described in this research, you will achieve the following. l. You will motivate the innovators. 2. You will spare yourself of many trial and errors and risks thus increasing the effectiveness, 3. You will eliminate the obstacles to innovation. 4. You will continue to innovate and will be able to assess the results through visible index.

  • PDF