• Title/Summary/Keyword: medical error

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Determination of the Virtual Focus Position for Electron Beam with Air Scanning (전자선에서 Virtual Source Distance의 위치 결정)

  • Kwon Kyung Tea;Youn Wha Ryong;Park Kwang Ho;Kim Chung Man
    • The Journal of Korean Society for Radiation Therapy
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    • v.6 no.1
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    • pp.89-93
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    • 1994
  • Authors have measured virtual source distance of electron beam from CL/1800 medical linear accelerator, with newly designed method. Beam scanning was performed with the direction of beam axis in the air. Compared results between this study and well established in phantom measurement shows good agreement with in experimental error. And we have found that build-up cap plays very important role in air measurement because of charge build up. The method of in-air measurement of virtual source distance is very easy to set-up and generate accurate results.

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Development of the Whole Body 3-Dimensional Topographic Radiotherapy System (3차원 전신 정위 방사선 치료 장치의 개발)

  • Jung, Won-Kyun;Lee, Byung-Yong;Choi, Eun-Kyung;Kim, Jong-Hoon;An, Seung-Do;Lee, Seok;Min, Chul-Ki;Park, Cham-Bok;Jang, Hye-Sook
    • Progress in Medical Physics
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    • v.10 no.2
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    • pp.63-71
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    • 1999
  • For the purpose of utilization in 3-D conformal radiotherapy and whole body radiosurgery, the Whole Body 3-Dimensional Topographic Radiation Therapy System has been developed. Whole body frame was constructed in order to be installed on the couch. Radiopaque catheters were engraved on it for the dedicated coordinate system and a MeV-Green immobilizer was used for the patient setup by the help of side panels and plastic rods. By designing and constructing the whole body frame in this way, geometrical limitation to the gantry rotation in 3-D conformal radiotherapy could be minimized and problem which radiation transmission may be altered in particular incident angles was solved. By analyzing CT images containing information of patient setup with respect to the whole body frame, localization and coordination of the target is performed so that patient setup error may be eliminated between simulation and treatment. For the verification of setup, the change of patient positioning is detected and adjusted in order to minimize the setup error by means of comparison of the body outlines using 3 CCTV cameras. To enhance efficiency of treatment procedure, this work can be done in real time by watching the change of patient setup through the monitor. The method of image subtraction in IDL (Interactive Data Language) was used to visualize the change of patient setup. Rotating X-ray system was constructed for detecting target movement due to internal organ motion. Landmark screws were implanted either on the bones around target or inside target, and variation of target location with respect to markers may be visualized in order to minimize internal setup error through the anterior and the lateral image information taken from rotating X-ray system. For CT simulation, simulation software was developed using IDL on GUI(Graphic User Interface) basis for PC and includes functions of graphic handling, editing and data acquisition of images of internal organs as well as target for the preparation of treatment planning.

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The Effectiveness of the Error Reporting Promoting Program on the Nursing Error Incidence Rate in Korean Operating Rooms

  • Kim, Myoung-Soo;Kim, Jung-Soon;Jung, In-Sook;Kim, Young-Hae;Kim, Ho-Jung
    • Journal of Korean Academy of Nursing
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    • v.37 no.2
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    • pp.185-191
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    • 2007
  • Purpose. The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. Methods. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. Results. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Conclusion. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.

Dosimetric Measurement for 4MV X-Ray Linear Accelerator with Asymmetric Collimator System (4MV 선형가속기에서의 비대칭 콜리메이터의 선량측정)

  • 이병용;최은경;장혜숙
    • Progress in Medical Physics
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    • v.1 no.1
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    • pp.69-73
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    • 1990
  • Dosimetric measurement of an asymmetric collimator system was performed, using water phantom system for 4MV X-ray linear accelerator. We have studied the system of dose calculation with those measured result. We compared the field size factor and the percent depth dose for asymmetric collimator to those factor for symmetric fields. The results show that we can use symmetric field data directly within 1% error, if we consider the off axis ratio(OAR).

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The Dosimetric Effects on Scallop Penumbra from Multi-leaf Collimator by Daily Patient Setup Error in Radiation Therapy with Photon (광자선 치료시 Setup 오차에 따르는 Multi-leaf Collimator의 Scallop Penumbra 변화 효과)

  • Yi, Byong-Yong;Cho, Young-Kap;Chang, Hye-Sook
    • Radiation Oncology Journal
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    • v.14 no.4
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    • pp.333-338
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    • 1996
  • Purpose : To evaluate the clinical implications of scallop penumbra width that comes from multileaf collimator(MLC) effect by the daily routine patient setup error. Materials and Methods : The anales of $0^{circ},{\;}15^{circ},{\;}30^{circ},{\;}45^{circ},{\;}60^{circ},{\;}and{\;}75^{circ}$ inclined -radiation blocked fields were generated using the both conventional cerrobend block and the MLC. Film dosimetry in the phantom were performed to measure penumbral widths of differences between the dose distributions from the cerrobend block and those of respect the MLC. The patient setup error effect on scallop penumbra was simulated with respect to the table of setup error distribution. Same procedures are repeated for the cerrobend block generated field. Results : There are penumbral widths of to 3mm difference between the dose distributioins from two kinds of field shaping tools, the conventional block and the MLC with 4mm setup error model and resolution of 1cm leaf at the isocenter. Conclusion : We need not additive margin for MLC, if planning target volume is selected according to the recommendation of ICRU 50. For particular cases, we can include the target volume with less than 3mm additive margin.

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Causes and Predictive Factors Associated with "Diagnosis Changed" Outcomes in Patients Notified as Tuberculosis Cases in a Private Tertiary Hospital

  • Kang, Byung Ju;Jo, Kyung-Wook;Park, Tai Sun;Yoo, Jung-Wan;Lee, Sei Won;Choi, Chang-Min;Oh, Yeon-Mok;Lee, Sang-Do;Kim, Woo Sung;Kim, Dong Soon;Shim, Tae Sun
    • Tuberculosis and Respiratory Diseases
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    • v.75 no.6
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    • pp.238-243
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    • 2013
  • Background: The aim of our study was to evaluate the "diagnosis changed" rate in patients notified as tuberculosis (TB) on the Korean TB surveillance system (KTBS). Methods: A total of 1,273 patients notified as TB cases on the KTBS in one private tertiary hospital in 2011 were enrolled in the present study. Patients were classified into three groups: "diagnosis maintained", "diagnosis changed" (initially notified as TB, but ultimately diagnosed as non-TB), and "administrative error" (notified as TB due to administrative errors). Results: Excluding 17 patients in the "administrative error" group, the "diagnosis maintained" and "diagnosis changed" groups included 1,097 (87.3%) and 159 patients (12.7%), respectively. Common causes of "diagnosis changed" were nontuberculous mycobacterial (NTM) disease (51.7%, 61/118), and pneumonia (17.8%) in cases notified as pulmonary TB, and meningitis (19.5%, 8/41) and Crohn's disease (12.2%) in cases notified as extrapulmonary TB. Being older than 35 years of age (odds ratio [OR], 2.18) and a positive acid-fast bacilli stain (OR, 1.58) were positive predictors and a TB-related radiological finding (OR, 0.42) was a negative predictor for a "diagnosis changed" result via multivariate logistic regression analysis in pulmonary TB cases. Conclusion: Because of a high "diagnosis changed" rate in TB notifications to the KTBS, the TB incidence rate measured by the KTBS may be overestimated. Considering the worldwide trend toward increased NTM disease, the "diagnosis changed" rate may increase over time. Thus, when reporting the annual TB notification rate in Korea, the exclusion of "diagnosis changed" cases is desirable.

A Study on the Compensation of Blood Pressure Caused by the Change of Arterial Pressure Shape (동맥압 형태변화에 따른 혈압 보정에 관한 연구)

  • Lim, S.S.;Park, K.L.;Lee, K.J.
    • Proceedings of the KOSOMBE Conference
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    • v.1998 no.11
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    • pp.177-178
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    • 1998
  • This paper is a study on compensation for error in estimation of mean pressure according to the change of arterial pressure shape. Because arterial pressure shape affects the mean pressure and blood volume which are important factors for measurement of blood pressure(BP), change of arterial pressure shape cause BP measurement error. In order to solve this problem, we add the compensation function C($\alpha$), depending on arterial pressure shape, to mathematical oscillometric model. Consequently, we could accurately estimate the blood pressure by correcting of the error using compensation function.

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Suggestions for the Improvement of Medical Humanities Education (인문사회의학 교육과정 개선을 위한 제안)

  • Jeon, Wootaek
    • Korean Medical Education Review
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    • v.12 no.1
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    • pp.23-31
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    • 2010
  • Medical humanities has become a third area of medical education following basic and clinical medicine. Also, in the national evaluation of medical schools, medical humanities education is an important factor. However, there are many difficulties in teaching medical humanities in medical schools. First, it is still an unfamiliar education area to medical schools and professors. Second, still, there is no consensus on the definition and contents of this education. Third, it is usually very difficult to find professors who have interest and the ability to teach medical humanities. Fourth, even medical students do not understand why they should study medical humanities and sometimes do not eagerly participate in class. This paper suggests some solutions for these problems. First, medical humanities need to be divided into sections according to how easily the contents can be accepted by existing medical education system and apply these sections in the introduction of this education gradually and in stage. One example of the division can be as follows: Group 1) medical ethics and medical law which can be most easily accepted. Group 2) medical communication skills which can be relatively easily accepted. Group 3) medical history and medical professionalism which is relatively difficult to accept, and Group 4) medical philosophy, medicine and music, medicine and literature, medicine and art, medicine and religion, etc. which is the most difficult to accept. In this paper, four things are suggested. Second, divide the contents into mendatory courses and elective courses. Third, allocate the contents throughout the four years from the first year though the fourth year according to the spiral curriculum model. This paper reports some new ideas and methods for medical humanities education. First, to stimulate students' participation, several methods were applied in a large size lecture and student projects. Second, the emphasis of writing in class and evaluation were discussed. Third, the provision of hands on experience is more emphasized than lectures. Fourth, inviting some doctors who work in non-medical areas such as journalism, pharmaceutical industry, etc is suggested. Trial and error is inevitable in this education, but it is essential in molding a good doctor, so medical professors who are interested or in charge of this medical humanities education need to share their ideas and experiences.

A Pilot Study on Developing a Patient Safety Curriculum Using the Consensus Workshop Method (환자안전 교육과정 개발 사례 연구)

  • Lee, Seung-Hee;Shin, Jwa-Seop;Huh, Nam-Hee;Yoon, Hyun Bae
    • Korean Medical Education Review
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    • v.15 no.3
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    • pp.151-158
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    • 2013
  • Patient safety is achieved through systematic improvement based on the knowledge and willingness of medical professionals. A systematic longitudinal curriculum for patient safety is essential to prepare medical students and professionals. The purpose of this article is to introduce our experience with a 'workshop for developing a patient safety curriculum' and to compare the results with previous studies. The workshop comprising 15 medical professors and patient safety experts met for 2 days. The Consensus Workshop method was applied, collecting opinions from all of the members and reaching consensus through the following stages: context, brainstorm, cluster, name, and resolve. The patient safety curriculum was developed by this method, covering patient safety topics and issues, and teaching and assessment methods. A total of 7 topics were extracted, 'activities for patient safety, concepts of patient safety, leadership and teamwork, error disclosure, self-management, patient education, policies.' Issues, teaching methods, and assessment methods were developed for each topic. The patient safety curriculum developed from the workshop was similar to previous curricula developed by other institutions and medical schools. The Consensus Workshop method proved to be an effective approach to developing a patient safety curriculum.

Development of m-Health Application based on Medical Informatics Standards (의료정보 표준에 기반 한 m-Health 어플리케이션 개발)

  • Park, Hyun Sang;Kim, Hwa Sun;Jung, Hyun Jung;Cho, Hune
    • Journal of Korea Multimedia Society
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    • v.17 no.5
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    • pp.640-653
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    • 2014
  • Recently medical consumers pursue high leveled quality of life through active promotion, prevention, management activity of health as the importance of health during home life is emerged to meet the aging society and chronic diseases. In addition, people are directed to the m-Health for managing yourself their health by using smartphone and various personal health devices, if necessary transmits health data to the physician himself. In the previous studies, m-Health Application were developed and applied in the real clinical environment by adopting the medical information standards was rarely conducted. Therefore, in this study, the m-Health application platform was developed. Developed application was communicate with IEEE 11073 standard protocol using the Bluetooth Health Device Profile in personal health device via smart phone to process blood pressure information, and it converted to HL7 V2.6 ORU_R01 message for send to remote medical server. In addition, we tested the interoperability and safety of the developed application for 23 inpatient and 17 outpatient at D University Hospital. As a result, the blood pressure information has been transmitted without error.