• 제목/요약/키워드: failure cases

검색결과 2,167건 처리시간 0.031초

Analysis of court rulings on involuntary manslaughter or at-fault injury due to professional negligence by pediatric nurses: a systematic content analysis study

  • Song, Sung Sook;Kim, Eun Joo
    • Child Health Nursing Research
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    • 제28권2호
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    • pp.91-102
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    • 2022
  • Purpose: This study systematically analyzed cases in South Korea wherein nurses were prosecuted for involuntary manslaughter or injury due to professional negligence in pediatric care. Methods: We analyzed the precedents using the methodology of Hall and Wright (2008) and Austin (2010). Of the 618 cases retrieved from the Supreme Court Decisions Retrieval System in South Korea, we selected the 12 cases in which children were the victims and nurses were the defendants, using a case screening methodology. Results: The most frequent penalty was a fine, and newborns were the most frequent victims. The distribution of cases according to Austin's violation categories was: improper administration of medications (n=5), failure to monitor for and report deterioration (n=4), ineffective communication (n=4), failure to delegate responsibly (n=4), failure to know and follow facility policies and procedures (n=1), and improper use of equipment (n=1). Conclusion: To ensure the safety of children, nurses are required to teach and practice a high standard of care. Nursing education programs must improve nurses' awareness of their legal obligations. Nursing organizations and leaders should also work towards enacting effective nursing laws and ensuring that nurses are aware of their legal rights and responsibilities.

종속고장을 고려한 전력시스템의 신뢰도 평가 (Reliability Analysis of Power System with Dependent Failure)

  • 손현일;권기량;김진오
    • 조명전기설비학회논문지
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    • 제25권9호
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    • pp.62-68
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    • 2011
  • Power system needs to sustain high reliability due to its complexity and security. The reliability prediction method is usually based on independent failure. However, in practice, the Common Cause Failures(CCF) and Cascading failure occur to the facilities in power system as well as independent failures in many cases. The CCF and Cascading failure turn out the system collapse seriously in a wide range. Therefore to improve the reliability of the power system practically, it is required that the analysis is conducted by using the CCF and Cascading failure. This paper describes the CCF and Cascading failure modeling combined with independent failure. The incorporated model of independent failure, CCF and cascading failure is proposed and analyzed, and it is applied to the distribution power system in order to examine this method.

사례기반추론을 이용한 웹 기반 건설실패사례 정보시스템 (A Web-Based Construction Failure Information System using Case-Based Reasoning)

  • 박용성;오치돈;전용석;박찬식
    • 한국건설관리학회논문집
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    • 제9권6호
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    • pp.257-267
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    • 2008
  • 국내 건설 산업에서 실패정보는 사례중심의 비체계적인 문서형태로 관리되고, 통계적 분석결과 정보수준의 자료로 제시되고 있다. 이는 건설실패정보의 활용을 통하여 건설프로세스가 지속적으로 개선될 수 있다는 긍정적인 측면을 간과한 건설실무자의 인식의 부재에 기인한다. 이에 본 연구는 건설실패정보의 관리 및 활용에 대한 문제점을 인식하고, 반복적으로 발생되는 건설실패를 사전에 예방할 수 있도록 실패정보를 체계적으로 관리, 공유, 학습, 활용할 수 있는 웹 기반 건설실패사례 정보시스템을 구축하기 위한 목적으로 수행되었다. 본 연구에서 개발된 건설실패사례 정보시스템은 웹과 사례기반추론기법을 이용하여 가장 유사한 과거 사례가 검색될 수 있도록 구현하였으며, 건설실패정보를 체계적으로 관리할 수 있고, 실패사례를 통한 간접적 지식습득 및 미래의 건설프로젝트의 실패발생 예방대책을 수립하는데 활용될 수 있을 것이다.

만성 신부전증 환자에서의 동정맥루조성술 (Clinical Analysis of Arteriovenous Fistula Formation for CRF Patiients)

  • 김응중;이영;박진석
    • Journal of Chest Surgery
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    • 제27권8호
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    • pp.669-676
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    • 1994
  • Because the number of patients who require maintenance hemodialysis is increasing in number recently, angioaccess has become important to many vascular surgeons participating in the management of such patients.The authors created 269 arteriovenous fistulas[AVF] for angioaccess in 229 patients with chronic renal failure[CRF] at the Department of Thoracic and Cardiovascular Surgery in Chungnam National University Hospital during the period from August 1990 to March 1993. We analyzed the results of 260 operations for 220 patients except 9 patients who were lost during the follow up period. We performed snuffbox AVF in 171 cases, classic radiocephalic AVF in 46 cases, direct AVF at other site in 5 cases, forearm Gore-Tex AVF in 29 cases, and upper arm Gore-Tex AVF in 9 cases. We experienced 13 cases of operative failures, 11 cases of early complications, and 60 cases of late complications including obstructions during follow-up period. The 1 year, 2 year and 3 year patency rates of snuffbox AVF[Group 1], classic radiocephalic AVF[Group 2], and Gore-Tex AVF[Group 3] are like followings; 89, 84, 76% in group 1, 84, 75, 68% in group 2, and 79, 66, 55% in group 3. It showed a statistically significant difference between group 1, 2 and group 3.

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전방 십자인대 재재건술의 분석 (Analysis of revision anterior cruciate ligament reconstruction)

  • 박찬희;송은규;선종근;임지현;강경도;이태민
    • 대한정형외과스포츠의학회지
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    • 제10권2호
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    • pp.47-53
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    • 2011
  • 목적: 전방십자인대 재건술의 수가 증가하면서, 재건술의 실패로 인한 재재건술의 빈도 또한 증가하고 있다. 따라서 저자는 전방십자인대 재건술 후 발생한 이식건 실패의 원인 및 전방십자인대 재재건술 후의 임상적 결과를 분석하였다. 대상 및 방법: 1998년 2월부터 2010년 7월까지 전방십자인대 재건술 실패에 대하여 전방십자인대 재재건술을 시술받은 후 최소 12개월 이상 추시가 가능하였던 36예를 대상으로 하였다. 재건술 후 재재건술까지의 평균기간은 60(5~334)개월이었으며, 처음 전방십자인대 재건술을 시술 시 23예(63.9%)에서 동종 이식건을, 13예(36.1%)에서 자가 이식건을 사용하였다. 전방십자인대 재건술 실패의 주증상으로 불안정성이 가장 많았으며, 전방십자인대 재건술을 한번 시행 받았던 경우가 35예(97.5%), 두 번 시행 받았던 경우가 1예(2.5%)였다. 임상적 결과는 Lysholm 슬관절 점수, Tegner activity 점수를 이용하여 평가하였으며, 안정성은 Lachman 및 pivot shift 검사와 Telos device를 이용하여 평가하였다. 결과: 환자의 평균 추시 기간은 21(12~40)개월이었으며, 전방십자인대 재건술의 실패원인으로는 외상이 19예(52.8%)로 가장 많았고, 대퇴 터널의 부정위치가 13예(36.1%), 경골부 터널의 부정위치가 1예(2.8%), 골융합의 실패 3예(8.4%)로 나타났다. 전방십자인대 재재건술을 시행할 시 34예(94%)에서 동종이식건을, 2예(6%)에서 자가 이식건을 사용하였으며, 21예에서 반월상 연골판 손상이 동반되었다(내측 반월상 연골판 손상 14예, 외측 반월상 연골판 손상 7예). Lysholm 슬관절 점수는 술전 66.5점에서 술후 최종 추시시 92점으로 호전되었다(p<0.01). 환자의 대부분은 수술 결과에 만족(92%)하고 있었다. Tegner activity 점수는 술전 2.0점에서 술후 6.2점으로 호전되었다(p<0.01). Lachman 및 pivot shift 검사에서 33예, 30예가 Gr I 이하로 호전되었으며, Telos device를 이용한 안정성 검사에서는 양측 차이 정도는 술전 평균 15.5 mm에서 술후 최종 추시시 4.5 mm로 의미있게 호전되었다(p<0.01). 환자의 대부분은 수술 결과에 만족(92%)하고 있었다. 결론: 전방십자인대 재 재건술은 1년 이상 추시 결과 약간의 전방 불안정성이 존재하였으나, 임상적 결과 및 환자의 주관적 만족도에 있어서는 우수한 결과를 보였다.

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흉부 손상의 임상적 고찰 (Clinical Evaluation of Chest Trauma)

  • 김용한
    • Journal of Chest Surgery
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    • 제25권9호
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    • pp.968-975
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    • 1992
  • A clinical analysis was performed on 404 cases of the chest trauma who were admitted and treated at department of thoracic and cardiovascular surgery, Chung Ang University, Yong San Hospital during the past 8 years from July 1984 to April 1992. The results were as follows. 1. The sex ratio was 3: 1 with male predominence. 2. The common age groups were 3rd, 4th, 5th and 6th decades. 3. The most common chief complaint was chest pain[58.2%]. 4. Of 404 cases of chest trauma, 50 cases were resulted from penetrating injuries whereas 354 cases were from non penetrating injuries. The most common cause of the non penetrating injuries was traffic accident[234/354, 66.1%] and of the penetrating injuries were stab wound[47/50, 94%]. 5. The left thorax was the preferred site of chest trauma. 6. The range of hospital stay was from less than 1 week to over 6 weeks and the average duration was about 2 weeks. 7. The common chest trauma was rib fracture[51.6%] and others were simple contusion [18.8%], hemothorax[14.6%], hemopneumothorax[14.9%] and pneumothorax[8.7i]. The rib fracture was prevalent between 4th to 9th rib laterally. 8. There were 92 cases of associated injuries which were bone fracture[66/92, 71.7%], head injury[17/92, 18.5%] and abdominal injury[9/92, 9.8%]. 9. The methods of treatment were conservative management[58.6%], closed tho-racostomy[23.3%], open thoracotomy[3.4%] and others. 10. There were 28 cases[6.9%] of complication, such as pneumonia, atelectasis, emp-yema, respiratory failure and others. 11. The overall mortality was 2.5%[10 cases] and causes of death were hypovolemic shock, acute renal failure, adult respiratory distress syndrome, sepsis and multiple organ failure.

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두경부 선낭암의 생물학적 특성과 치료 (Biological behavior and Treatment of Adenoid Cystic Carcinoma in The Bead and Neck)

  • 오원용;조관호;서창옥;김귀언
    • Radiation Oncology Journal
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    • 제2권2호
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    • pp.191-202
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    • 1984
  • Biological behavior and treatment results of 33 patients with Adenoid Cystic Carcinoma (ACC) in the Head and Neck at Yonsei Cancer Confer for 10 years between 1971 and 1980 were retrospectively analysed. Most common, primary site was minor salivary glands such as maxillary sinus, nasal cavity and base of tongue. The typical biological behavior of these tumors was very slowly in growth with long time of duration(mean 19 months) from 1 month to 10 years and more frequent of nerve invasion but rare invasion of neck nodes. Local control and failure pattern in the results of treatment, 16 of 17 patients with irradiation alone were seen complete or partial response but 5 cases of locoregional recurrence, 2 cases of failure of neck node and 4 cases of distant metastasis as lung and brain. On the other hand, among 10 cases of surgery and postoperative irradiation, 2 cases of locoregional failure and 3 cases of distant metastasis as lung and bone. 2 of 4 cases with surgery alone were recurred within primary site. Actuarial overall NED survival at 3 ana 10 years were $52.6\%$ and $42.8\%$, respectively. Survival rate of 10 Patients with surgery and Postoperative irradiation was more high than 17 Patients of radiation alone. Therefore, we have known that surgery with postoperative adjunctive irradiation is most effective treatment modality of adenoid cystic carcinoma in the head and neck. Primary site, treatment modality and with or without nerve ana bone invasion have influenced on prognosis.

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심장판막 이식에 관한 연구 (Cardiac Valve Replacement: A Report of 16 Cases)

  • 김주현;이영균
    • Journal of Chest Surgery
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    • 제8권2호
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    • pp.89-100
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    • 1975
  • Sixteen cases of cardiac valve replacements have been done in this department since 1970. Twelve cases of mitral valve replacement were done with Beall valve, 2 cases of aortic valve replacement with Starr-Edwards and Magoven valve and 2 cases of double valve replacement using Beall valve for mitral and Magovern valve for aortic. Three patients [18.8%] died during operation. Two cases [12.5%] of hospital mortality occurred because of congestive heart failure and asphyxia due to tracheomalacia 3 months after operation. Follow-up studies from two to 27 months showed excellent results except three cases of late mortality [18.8 %]. Thromboembolism occurred in two double valve replacement patients[12.5%]who were fatal.

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감염성 심내막염의 외과적 치료 (Surgical Treatment of Native Valve Endocarditis)

  • 김애중;김민호;김공수
    • Journal of Chest Surgery
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    • 제28권9호
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    • pp.822-828
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    • 1995
  • This paper reports 15 native valve endocarditis cases had surgical operation in the past 10 years at the department of Cardiovascular and Thoracic Surgery, Chonbuk National University Hospital. In this study, 10 cases out of 15 were in class I or II by the New York Heart Association functional classification. None of the cases had a history of taking addictive drugs. Five cases were congenital heart disease, three cases were rheumatic heart disease and two cases were degenerative heart disease. Thus 10 cases had the underlying disease. All cases had antibiotics treatment for 3 to 6 weeks before operation. In the culture test, only four cases were positive in the blood culture and one case was positive in the excised valve culture. Organisms on blood and valve culture were Streptococcus epidermis, Streptococcus viridans, Staphylococcus aureus and Staphylococcus epidermidis. In the 10 cases without ventricular septal defect, the aortic valve was involved in four, mitral in four, both in two and involved valves in the 5 cases with ventricular septal defect were tricuspid in three, pulmonic in two. Eight cases had operation because they showed moderate congestive heart failure due to valvular insufficiency and vegetation with or without embolism. Seven cases had operation because they showed persistent or progressive congestive heart failure and/or uncontrolled infection. Five cases with ventricular septal defect underwent the closure of ventricular septal defect, vegetectomy and leaflet excision of the affected valves without valve replacement. In the cases without ventricular septal defect, the affected valves were replaced with St. Jude mechanical prosthesis. Postoperative complications were recurrent endocarditis in two, embolism in one, allergic vasculitis in two, spleen rupture in one and postpericardiotomy syndrome in one. At the first postoperative day, one case died of cerebral embolism. At the 11th postoperative month, one case died of recurrent endocarditis and paravalvular leakage in spite of a couple of aortic valve replacement. In the survived cases[13 cases in this study , all cases but one became class I or II by the New York Heart Association functional classification.

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Clinical Analysis of Tennis Elbow - 148 Cases -

  • Cho Duck Yun;Hahm Young Gil;Lee Joon Myoug
    • 대한견주관절학회:학술대회논문집
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    • 대한견주관절학회 1995년도 학술대회
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    • pp.22-22
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    • 1995
  • One hundred and forty-eight cases of tennis elbow were treated by conservative managements firstly such as rest, medication, immobilization, physical therapy and local steroid injection, from Jan. 1985 to Jun. 1994 at Department of Orthopaedic Surgery, National Medical Center. Among the 148 cases, 16 cases who failed conservative managements, were treated with Nirschl & Pettrone operation. The results were summarized as follows, 1. Among the 148 cases, 110 cases$(74\%)$ were female, and 61 cases$(41.2\%)$ were in the age group 41 to 50, and mean age was 42.3 2. Ninety-nine cases were housewives and only 15 cases were related to sports. 3. The results 116cases$(78\%)$, of conservative treatment were excellent and good 10 fair and failure in 32 cases$(22\%)$, by Nirschl and Peettrone assessment. 4. Among the 16 cases who were treated with Nirschl and Pettrone operation, excellent result was obtained 10 7cases, good in 3 cases, fair in 4cases and failure in 2 cases. 5. Recurrence was developed in 18 cases$(12.2\%)$, and we obtained excellent & good result in 17 cases with both conservative and operative treatment. Above results suggest that the term, tennis elbow is a misnomer because it occurs more commonly in non-athletes such as housewives than in tennis players. So it seems to be a occupational disease rather than sports injury. Now, we propose eliminate of the term, elbow and substitute with terminology that described the true understanding and therapeutic orientation of it.

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