• Title/Summary/Keyword: incident reporting

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A Study on the Selection of VTS Marine Incident Classification Criteria at the Busan Port (VTS 관점의 준해양사고 분류기준 선정에 관한 연구 - 부산항을 대상으로 -)

  • Ha, Jong-Min;Park, Young-Soo;Park, Sang-Won;Jeong, Jae-Yong
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.26 no.6
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    • pp.615-623
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    • 2020
  • In order to prevent the dangers of major marine accidents, it is very important to be aware of in advance through marine incidents in the background of Heinrich's law, formulated by the safety pioneer who is credited with focusing on workplace safety with emphasis on the human element. At least 11 cases of collision accidents occurred in the Busan VTS area from January 1st to December 31st, 2019, and 24 cases of VTS marine incidents were reported during the same period. According to Heinrich's law, there could be many more potentially risky situations besides the 24 reported cases. In this study, the criteria for VTS marine incidents were established through advanced research and a survey of VTS operators, and analysis of 24 cases of VTS marine incidents in the Busan VTS area. Traffic surveys were conducted for three days to identify potentially hazardous situations. According to the survey, there were 216 cases of VTS marine incidents, and within a year, it is estimated there could be about 26,280 cases. Even if conditions such as "missing VHF communication feedback" which is an important cause of marine incidents, are not reflected, there are many potential risks in the VTS area. Thus, it is vital to strengthen the VTS marine incident reporting system.

Current Status of Patient Safety Regulations, Guidelines and Support Mechanisms in Korean Hospitals

  • Lee, Jae Ho;Kim, Jeong Eun;Kim, Suk Wha;Lee, Sang Il;Jung, Yoen Yi;Kim, Moon Sook;Jang, Seon Mi
    • Perspectives in Nursing Science
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    • v.10 no.2
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    • pp.158-166
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    • 2013
  • Purpose: This study was conducted to investigate patient safety regulations and guidelines in order to understand their current status, and to examine support measures to improve patient safety in Korean hospitals. Methods: The participants were the safety officers from hospitals with 200 or more beds and 112 hospitals responded to the online survey. The questions covered patient safety regulations, the performance level of patient safety activities, patient safety incident reporting systems, the dedicated professional, training, support mechanisms, and expectations of reporting systems. Results: Among preventative measures, fall prevention and hand hygiene were reported to be most widely practiced (92% and 91%, respectively). Time-out for invasive procedures showed a relatively low practice rate at 70%. Among patient care activities, transfusion, surgery and sedation, medication, and infection management were performed by 84, 74, 93 and 93% of the hospitals, respectively. Patient safety activities included patient safety committee, patient safety cooperation between decision-making bodies, patient safety workshops, seminars, lectures, and training for employees. Conclusion: Patient safety regulations and guidelines have not yet been sufficiently prepared, and a public institution such as a certification authority is of crucial importance to enforce these guidelines.

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Developing national level high alert medication lists for acute care setting in Korea (국내 급성기 의료기관 고위험 의약품 목록 도출)

  • Han, Ji Min;Heo, Kyu-Nam;Lee, Ah Young;Min, Sang il;Kim, Hyun Jee;Baek, Jin-Hee;Rho, Juhyun;Kim, Sue In;Kim, Ji yeon;Lee, Haewon;Cho, Eunju;Ah, Young-Mi;Lee, Ju-Yeun
    • Korean Journal of Clinical Pharmacy
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    • v.32 no.2
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    • pp.116-124
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    • 2022
  • Background: High-alert medications (HAMs) are medications that bear a heightened risk of causing significant patient harm if used in error. To facilitate safe use of HAMs, identifying specific HAM lists for clinical setting is necessary. We aimed to develop the national level HAM list for acute care setting. Methods: We used three-step process. First, we compiled the pre-existing lists referring HAMs. Second, we analyzed medication related incidents reported from national patient safety incident report data and adverse events indicating medication errors from the Korea Adverse Event Reporting System (KAERS). We also surveyed the assistant staffs to support patient safety tasks and pharmacist in charge of medication safety in acute care hospital. From findings from analysis and survey results we created additional candidate list of HAMs. Third, we derived the final list for HAMs in acute care settings through expert panel surveys. Results: From pre-existing HAM list, preliminary list consisting of 42 medication class/ingredients was derived. Eight assistant staff to support patient safety tasks and 39 pharmacists in charge of medication safety responded to the survey. Additional 44 medication were listed from national patient safety incident report data, KAERS data and common medications involved in prescribing errors and dispensing errors from survey data. A list of mandatory and optional HAMs consisting of 10 and 6 medication classes, respectively, was developed by consensus of the expert group. Conclusion: We developed national level HAM list for Korean acute care setting from pre-existing lists, analyzing medication error data, survey and expert panel consensus.

Incidence of Cutaneous Injury in Clinical Nurses (병원 간호사의 경피 상해 발생 실태)

  • Shin Eun-Jung;Moon Jung-Soon
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.12 no.2
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    • pp.215-222
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    • 2005
  • Purpose: To identify the incidence of cutaneous injury in clinical nurses. Method: From Feb.1 to 28, 2005, 276 clinical nurses were surveyed by questionnaire. Results: 1. Of the nurses, 53.6% had at least one incidence of cutaneous injury, and the mean number of injuries was 1.34. A higher incidence rate for cutaneous injury was found in nurses who were under the age of 25, unmarried and who had less than 3 years career experience. 2. The major causes of injury were syringe needles at 65.0%, and medical instrument were next followed by sharp objects or blades. The injuries occurred when the nurses were rearranging equipment after care (25.2%), taking blood samples (22.8%), separating syringes and needles (17.1%), during surgical operations (14.2%), and distribution of medications, treatments and recapping of needles (5.7% each). The hands were the most common body parts injured, and the most prevalent pathogens contaminating the instruments causing the injury were HBV syphilis, HCV and HIV in that order. 3. Of the injured nurses, 77.9% did not report the accident and 25.8% did not receive any treatment because there were no pathogens, it was a bother or there was difficulty reporting the incident. Conclusion: To reduce cutaneous injuries, intensive training and supervision may be needed for those of nurses under the age of 25, unmarried and with less than 3 years career experience.

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A Study on Efficient Operation of Safety Management System for Airport Organization (공항운영조직의 안전관리시스템(SMS) 운영 효율성 향상에 관한 연구)

  • An, Gyeong-Ryeong;Jang, Jing-Lun;Jang, Jung-Hwan;Lee, Chang-Ho
    • Journal of the Korea Safety Management & Science
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    • v.17 no.1
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    • pp.13-19
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    • 2015
  • Continued efforts to build up Safety Management System(SMS) and to improve its efficiency in airports, to which customers have direct access, are taken for granted due to continuous development of the aviation industry in both quantity and quality and rapid growth of air transportation market. This thesis proposed efficient operation methods of SMS for domestic airport organizations including Incheon International Airport(IIA), the largest airport in South Korea, aiming at strengthening aviation safety from the perspective of airport operators who play a pivotal role in service provider SMS. Those are consolidation of the existing safety management organizations and various improvements to promote voluntary incident reporting system. To draw a proposal for the improvements, conducted a research on domestic safety management status, carried out an analysis on operating conditions and did a research on ICAO regulations, domestic legal system as well as statistics data. Relevant studies and researches were also gathered and analyzed. A search for further improvements can also help increase operational efficiency and promoting a higher-level of safety awareness among operators can establish mature safety culture at airports.

Analysis of Risk Factors for Patient Safety Management (환자안전 관리를 위한 위험요인 분석)

  • Ahn, Sung-Hee
    • Journal of Korean Academy of Nursing Administration
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    • v.12 no.3
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    • pp.373-384
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    • 2006
  • Purpose: This is a pilot study to identify patient safety risk factors and strategies for patient safety management perceived by nurses. Methods: Data were collected and analyzed with an open questionnaire from April to May 2005, targeted on 100 nurses working in two hospitals. The issues were 'what are risk factors for patients, nurses, and other medical practitioners? How do they prevent with the aftermath of risk factors, causes of incidents?' For data analysis, types and frequency of risk factors were worked out, using the Australian Incident Monitoring System Taxonomy. Results: The types of patient safety risk factor perceived by nurses were as follows ; therapeutic devices or equipment, infrastructure and services (29.5%), nosocomial infections (16.3%), clinical processes or procedures (15.4%), behavior, human performance, violence, aggression, security and safety (12.2%), therapeutic agents (9.7%), injuries and pressure ulcers (8.7%), logistics, organization, documentation, and infrastructure technology (5.6%). Strategies for patient safety included training of prevention of infection, education about safety management for patients and medical professionals, establishment of reporting system, culture of care, pre-elimination of risk factors, cooperative system among employees, and sharing information. Conclusion: These results will be used to provide evidences for patient safety management and educational program.

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A Study on the State's Aviation Safety Audit Systems for the Improvement of the Integrated Railroad Safety Audit System (철도종합안전심사제도 발전을 위한 국가 항공안전감독체계 고찰)

  • Kim, Mhan-Woong;Oh, In-Tack;Shin, Jeong-Beom;Lee, Jong-Seock
    • Proceedings of the KSR Conference
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    • 2008.11b
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    • pp.1907-1915
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    • 2008
  • Recently the assurance of railroad safety is very important issue in KOREA because there are lots of changes in the railroad industries. The Railway Safety Act was established in order to cope with these changes effectively and prevent the railroad transportation accidents. According to this law, Korea Transportation Safety Authority (KOTSA) has been entrusted with 'Integrated Railroad Safety Audit (IRSA)'. Even though newly introduced IRSA is conducted smoothly, it is necessary to study the methodology and criteria of the state's safety audit system in other fields to improve the efficiency. In ICAO (International Civil Aviation Organization) Safety Management Manual, a state's safety programme embraces those regulations and directives for the conduct of safe operations from the perspective of aircraft operators and those providing air traffic services(ATS), aerodromes and aircraft maintenance. The safety programme may include provisions for such diverse activities as incident reporting, safety investigations, safety audits and safety promotion. To implement such safety activities in an integrated manner requires a coherent SMS(Safety Management System). In this paper, to improve the efficiency of IRSA, we investigated the ICAO's the State's Aviation Safety Audit Systems and ICAO Safety Management Manual. And through the result of investigation, we proposed the improvement concept of IRSA.

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What Will We Learn from the Paradigm Shift in Safety Science for Improving Patient Safety? (안전과학 패러다임의 전환과 환자안전의 개선)

  • Lee, Sang-Il
    • Quality Improvement in Health Care
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    • v.27 no.1
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    • pp.2-9
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    • 2021
  • Patient safety remains one of the most important health care issues in Korea. To improve patient safety, we have introduced concepts from the field of safety science such as the Swiss cheese model, and adopted several methodologies previously used in other industries, including incident reporting systems, root cause analysis, and failure mode and effects analysis. This approach has enabled substantial progress in patient safety to be made through undertaking patient safety improvement activities in hospitals that are systems-based, rather than individual-based. However, these methods have the shared limitation of focusing on negative consequences of patient safety. Therefore, the paradigm shift from Safety I to Safety-II in safety science becomes the focus of our discussion. We believe that Safety-II will complement, rather than replace, Safety-I in the discipline of patient safety. In order to continuously advance patient safety practices in Korea, it is necessary that Korea keeps abreast of the recent global trends and development in safety science. In addition, more focus should be placed on testing the feasibility of new patient safety approaches in real-world situations.

A Survey on Perception Level of the Radiological Technologist's about Culture of Patient Safety (환자안전 문화에 대한 방사선사의 인식도 조사)

  • Jeon, Min-Cheol;Kim, Young-Il;Jang, Jae-Uk;Han, Man-Seok;Seo, Sun-Youl
    • Journal of Digital Convergence
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    • v.12 no.2
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    • pp.423-430
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    • 2014
  • Patient safety culture for the general hospital to investigate the perception of radiological technologists, managing of the patient safety provides the Foundation for the safety activities as a basis to develop a program for providing. Patient safety culture for the general hospital to investigate the perception of Radiological technologists, the duration of the survey of the study on June 13, 2012 to June 20, and five general hospitals worked on Radiological technologists workers were material and analyzed the target of 198 (SPSS ver. 19.0). Patient safety activities within the Department, the factors affecting direct care, communication, medical malpractice, hospitals rated, safe for the patient safety culture and the reported accidents, dangerous and caused an accident, most feel that patient safety incident reporting system according to the results of evaluating medical accidents patient safety culture regarding recognition, work appeared in more than 25 years, even the most highly evaluated, the working period of 10 patient safety to 15 years the most highly. Therefore, General Hospital, Director of the patient safety culture improvement of radiation in order to have sufficient staffing, aggressive approach to patient safety issues, and safe working period of relapse prevention of accidents to the radiation as well as giving systematic consideration of mission medical accident reporting system will be active.

Occupational Lung Cancer Surveillance in South Korea, 2006-2009

  • Leem, Jong-Han;Kim, Hwan-Cheol;Ryu, Jeong-Seon;Won, Jong-Uk;Moon, Jai-Dong;Kim, Young-Chul;Koh, Sang-Baek;Yong, Suk-Joong;Kim, Soo-Geun;Park, Jae-Yong;Kim, In-Ah;Kim, Jung-Il;Kim, Jung-Won;Lee, Eui-Cheol;Kim, Hyoung-Ryoul;Kim, Dae-Hwan;Kang, Dong-Mug;Hong, Yun-Chul
    • Safety and Health at Work
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    • v.1 no.2
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    • pp.134-139
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    • 2010
  • Objectives: The lung cancer mortality in Korea has increased remarkably during the last 20 years, and has been the first leading cause of cancer-related deaths since 2000. The aim of the current study was to examine the time trends of occupational lung cancer and carcinogens exposure during the period 2006-2009 in South Korea, by assessing the proportion of occupational burden. Methods: We defined occupational lung cancer for surveillance, and developed a reporting protocol and reporting website for the surveillance of occupational lung cancer. The study patients were chosen from 9 participating university hospitals in the following 7 areas: Seoul, Incheon, Wonju, Daejeon, Daegu, Busan, and Gwangju. Results: The combined proportion of definite and probable occupational lung cancer among all lung cancers investigated in this study was 10.0%, 8.6%, 10.7%, and 15.8% in the years 2006 to 2009, respectively, with an average of 11.7% over the four-year study period. The main carcinogens were asbestos, crystalline silica, radon, polyaromatic hydrocarbons (PAHs), diesel exhaust particles, chromium, and nickel. Conclusion: We estimated that about 11.7% of the incident lung cancer was preventable. This reveals the potential to considerably reduce lung cancer by intervention in occupational fields.