• 제목/요약/키워드: fatal case

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전로사고 예방을 위한 인적오류 분석 (A Case Study on the Human Error Analysis for the Prevention of Converter Furnace Accidents)

  • 신운철;권준혁;박재희
    • 대한안전경영과학회지
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    • 제16권3호
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    • pp.195-200
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    • 2014
  • Occupational fatal injury rate per 10,000 population of Korea is still higher among the OECD member countries. To prevent fatal injuries, the causes of accidents including human error should be analyzed and then appropriate countermeasures should be established. There was an severe converter furnace accident resulting in five people death by chocking in 2013. Although the accident type of the furnace accident was suffocation, many safety problems were included before reaching the death of suffocation. If the safety problems are reviewed throughly, the alternative measures based on the review would be very useful in preventing similar accidents. In this study, we investigated the converter furnace accident by using human error analysis and accident scenario analysis. As a result, it was found that the accident was caused by some human errors, inappropriate task sequence and lack of control in coordinating work by several subordinating companies. From the review of this case, the followings are suggested: First, systematic human error analysis should be included in the investigation of fatal injury accidents. Second, multi man-machine accident scenario analyis is useful in most of coordinating work. Third, the more provision of information on system state will lessen human errors. Fourth, the coordinating control in safety should be performed in the work conducting by several different companies.

BEIR V 방법을 이용한 한국인의 방사선에 의한 암사망 예측 (Prediction of Fatal Radiation-Induced Cancer for Korean Using the BEIR V Method)

  • 황원태;한문희;조규성
    • Journal of Radiation Protection and Research
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    • 제21권3호
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    • pp.175-182
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    • 1996
  • BEIR V 방법을 사용하여 한국인이 단일 및 연속 방사선피폭을 받았을 경우 일생동안 방사선에 의한 암사망을 평가하였다. 단일피폭시 지배적으로 나타나는 암은 젊은층 피폭의 경우는 소화기암, 노령층피폭의 경우는 호흡기 암이었다. 한국인 모든 집단이 피폭받았을 경우, 지배적으로 나타나는 암은 소화기 암이었다. 출생에서 사망까지 1mGy/yr의 피폭을 연속적으로 받았을 경우, 방사선에 의한 모든 암의 발생은 자연 암발생의 3% 정도였다.

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Fatal Case of Cerebral Aspergillosis : A Case Report and Literature Review

  • Lee, Jae-Chang;Lim, Dong-Jun;Ha, Sung-Kon;Kim, Sang-Dae;Kim, Se-Hoon
    • Journal of Korean Neurosurgical Society
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    • 제52권4호
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    • pp.420-422
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    • 2012
  • Cerebral aspergillosis is rare and usually misdiagnosed because its presentation is similar to that of a tumor. The correct diagnosis is usually made intra-operatively. Cerebral abscess with fungal infection is extremely rare and few cases have been reported, but it carries a poor prognosis. A 73 year-old man presented with decreased visual acuity and paresis of the right cranial nerve III. Magnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extened to the anterior crainial fossa and the superior orbital fissure. During surgery, a well encapsulated pus pocket was found, and histopathological examination of the mass resulted in the diagnosis of aspergillosis. Despite appropriate anti-fungal treatment, the patient eventually died from fatal cerebral ischemic change and severe brain swelling. The correct diagnosis of cerebral aspergillosis can only be achieved by histopathological examination because clinical and radiological findings including MRI are not specific. Surgical intervention and antifungal therapy should be considered the optimal treatment. Early diagnosis and aggressive antifungal treatment provide good results.

메틸렌블루에 반응하지 않는 메트헤모글로빈혈증 1례 (A Fatal Case of Methylene Blue Threatment Failure in Methemoglobinemia)

  • 심지예;서연석;양종오;이은영;홍세용;길효욱
    • 대한임상독성학회지
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    • 제4권2호
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    • pp.151-154
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    • 2006
  • Acute toxic methemoglobinemia is an infrequent complication of the use of various drugs. Severe methemoglobinemia is very often fatal. Methylene blue is an effective drug in the treatment of methemoglobinemia patients. However, failure to respond to methylene blue has been described in patients with sulfhemoglobinemia, chlorate poisoning, and glucose-6-phosphate dehydrogenase deficiency. It is even possible that hemolysis may occur due to methylene blue treatment itself. We encountered a case of a 71-year-old woman who developed methemoglobinemia caused by alprazolam intoxication. She presented with hemolytic anemia and did not respond to methylene blue. In spite of concerted N-acetylcysteine therapy, the hemolytic anemia became aggravated and the patient died eleven days after intoxication.

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마비성 장폐색증에 병발된 간문맥 내 가스 (Hepatic portal venous gas in paralytic ileus)

  • 이지은;손민수;허준호;조선영;최선택;성영호
    • Journal of Yeungnam Medical Science
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    • 제31권1호
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    • pp.56-60
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    • 2014
  • Hepatic portal venous gas (HPVG) is a rare radiographic finding associated with severe intra-abdominal disease and fatal outcome. Most cases of HPVG are historically related to mesenteric ischemia accompanied by bowel necrosis. The current spread of computed tomography scan promotes not only the early detection of related severe diseases but also the identification of other causes of HPVG. It has been reported in many non-fatal conditions, such as inflammatory bowel disease, intra-abdominal abscess, bowel obstruction, paralytic ileus, endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy, and gastric dilatation. Among these, paralytic ileus is a very rare condition, with no case yet reported in South Korea. Reported herein is a case of HPVG in paralytic ileus, which was treated well internally and was promptly resolved.

A Case of Fatal Strongyloidiasis in a Patient with Chronic Lymphocytic Leukemia and Molecular Characterization of the Isolate

  • Kia, Eshrat Beigom;Rahimi, Hamid Reza;Mirhendi, Hossein;Nilforoushan, Mohammad Reza;Talebi, Ardeshir;Zahabiun, Farzaneh;Kazemzadeh, Hamid;Meamar, Ahmad Reza
    • Parasites, Hosts and Diseases
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    • 제46권4호
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    • pp.261-263
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    • 2008
  • Strongyloides stercoralis is a human intestinal parasite which may lead to complicated strongyloidiasis in immunocompromised. Here, a case of complicated strongyloidiasis in a patient with chronic lymphocytic leukemia is reported. Presence of numerous S. stercoralis larvae in feces and sputum confirmed the diagnosis of hyperinfection syndrome in this patient. Following recovery of filariform larvae from agar plate culture of the stool, the isolate was characterized for the ITS1 region of ribosomal DNA gene by nested-PCR and sequencing. Albendazole therapy did not have cure effects; and just at the beginning of taking ivermectin, the patient died. The most important clue to prevent such fatal consequences is early diagnosis and proper treatment.

한 작은 섬에서의 파라콰트 집단중독 (Mass paraquat poisoning in a small island community (case report))

  • 이성우;정태화;최강원;임정기;이덕형
    • Journal of Preventive Medicine and Public Health
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    • 제22권4호
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    • pp.454-465
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    • 1989
  • In a small island community with a population of less than 100 residents, nine persons died and five experienced severe illnesses during the period from November 1986 to May 1988. Their initial symptoms were sore throat and fever. Renal failure and hepatitis developed within one week after the onset. Oral mucosal ulcer developed in some cases. After one week, progressive respiratory failure and dyspnea developed evidently and severe respiratory distress and hypoxia preceded those fatal cases. Chest X-ray findings revealed bilateral diffuse multiple cystic lesion with occasional multiple large emphysematous bullae. Based on these features paraquat poisoning was diagnosed and route of poisoning was investigated. In three sources of drinking water, trace amount of paraquat was detected in November 1988, six months after the incidence of recent fatal case. In November 1988, soybean sauces and soybean pastes from 12 households were found contaminated with high concentration of paraquat, the cause could not be identified. The possibility of the contamination of drinking water as the cause of this mass poisoning has been suggested.

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심근 경색후 심실중격결손: 1례 보고 (Surgical Management of Postinfarction VSD - Report of 1 case -)

  • 윤태진
    • Journal of Chest Surgery
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    • 제24권9호
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    • pp.913-917
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    • 1991
  • Ventricular septal defect complicating myocardial infarction is rare but fatal condition which requires early surgical intervention before end-organ failure ensues from cardiogenic shock. Since the first successful repair by Cooley et al in 1956, surgical skills and strategies were developed and modified to a great extent, and we adopted the new repair technique in our case which stresses that minimal or no part of the infarcted septum and left ventricular wall be resected. This technique obviates the need to resect the infarcted part of the septum and prevents recurrence of an even larger VSD, and provides adequate size and shape of the left ventricle after of transinfarction left ventriculotomy.

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Nonsustained ventricular tachycardia during outpatient anesthesia: a case report

  • Kim, Keoungah;Kim, Seungoh
    • Journal of Dental Anesthesia and Pain Medicine
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    • 제21권4호
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    • pp.363-367
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    • 2021
  • During the perioperative period, anesthesiologists frequently observe cardiac tachyarrhythmia. Ventricular tachycardia is very rare in non-cardiac surgeries. However, it can be fatal when it occurs. Therefore, anesthesiologists should be watchful so as to not to miss ventricular tachycardia and take the appropriate steps to manage it promptly. We present a case, with a review of related literature, in which a non-sustained ventricular tachycardia was observed in a patient who visited the hospital for dental treatment.

Effect of anisotropic diffusion coefficient on the evolution of the interface void in copper metallization for integrated circuit

  • Choy, J.H.
    • 한국결정성장학회지
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    • 제14권2호
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    • pp.58-62
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    • 2004
  • The shape evolution of the interface void of copper metallization for intergrated circuits under electromigration stress is modeled. A 2-dimensional finite-difference numerical method is employed for computing time evolution of the void shape driven by surface diffusion, and the electrostatic problem is solved by boundary element method. When the diffusion coefficient is isotropic, the numerical results agree well with the known case of wedge-shape void evolution. The numerical results for the anisotropic diffusion coefficient show that the initially circular void evolves to become a fatal slitlike shape when the electron wind force is large, while the shape becomes non-fatal and circular as the electron wind force decreases. The results indicate that the open circuit failure caused by slit-like void shape is far less probable to be observed for copper metallization under a normal electromigration stress condition.