• 제목/요약/키워드: medical errors

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행우서옥본(杏雨書屋本) "황제내경태소(黃帝內經太素)" 권(卷)21, 권(卷)27의 출간(出刊) 의의(意義)와 그 내용에 대한 고찰(考察) (A study on Haengwuseook(杏雨書屋) Edition "Hwangjenaegyeong-Taeso(黃帝內經太素)"volume 21 and 27)

  • 김종현;백유상;장우창;정창현
    • 대한한의학원전학회지
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    • 제24권5호
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    • pp.159-175
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    • 2011
  • "Hwangjenaegyeong-taeso(黃帝內經太素)" is a classic work of Yang Sang-seon(楊上善), which comprises original articles of "Hwangjenaegyeong(黃帝內經)" along with "Somun(素問)", "Yeongchu(靈樞)", and "gapeul(甲乙)", as a one of the oldest annotated publications. Therefore, its significance lies in that "Hwangjenaegyeong-taeso(黃帝內經太素)" is a valuable work to reconstruct the original text of "Hwangjenaegyeong(黃帝內經)" and comprehend its fundamental ideas. The only printed edition of "Hwangjenaegyeong-taeso(黃帝內經太素)" was photocopied in 1981, and is currently known as 'Orient Edition'. While 'Orient Edition' was referred to as the draft for the latest revised edition, volume 21 and 27 were photocopied from hand-copied edition, not the original. The original publications of 'Orient Edition' have been stocked at 'Haengwuseook(杏雨書屋)' of Japan and were recently published. Hence, a comparative study between the two original volumes and the former ones has been conducted. Although the most of the differences were trivial, some may have led to distorted interpretation of the text. The errors of the former revised edition fall into a few specific categories, and the most significant ones were errors that were made during the hand-copying procedure. Moreover, there were errors that were made due to the low resolution of the former draft, and simple errors during the publishing. In this work, examples of such cases were presented, and the results were collected.

의료과오를 줄이기 위한 효율적인 병원서비스운영에 대한 실증적 연구 (An Empirical Study on the Efficient Hospital Service Operation Management for the Reduction of Medical Errors)

  • 이돈희;최강화
    • 품질경영학회지
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    • 제38권4호
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    • pp.491-503
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    • 2010
  • This paper presents a research model, which identifies a relationship between medical error reduction, efficiency of organizational systems, and employee satisfaction with organizational support. The proposed model was tested through hypotheses, based on data collected from 210 respondents from the medical staff of large -sized (i.e., more than 500 beds) residential hospitals in cities of South Korea. The results of the study showed that medical error reduction is associated with corrective system and employee satisfaction with organizational support. Therefore, it is very important that organizations improve their employees' satisfaction by providing sufficient support (e.g., information support and sharing, work guide book, etc.) for their work. In addition, in organizational systems, the corrective system has positive relationship with medical error reduction. In terms of corrective procedures, leaders or managers can make improvements by providing and supporting a friendly work environment where errors may be reported without blame and discussed in order to be corrected.

Major Causes of Preventable Death in Trauma Patients

  • Park, Youngeun;Lee, Gil Jae;Lee, Min A;Choi, Kang Kook;Gwak, Jihun;Hyun, Sung Youl;Jeon, Yang Bin;Yoon, Yong-Cheol;Lee, Jungnam;Yu, Byungchul
    • Journal of Trauma and Injury
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    • 제34권4호
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    • pp.225-232
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    • 2021
  • Purpose: Trauma is the top cause of death in people under 45 years of age. Deaths from severe trauma can have a negative economic impact due to the loss of people belonging to socio-economically active age groups. Therefore, efforts to reduce the mortality rate of trauma patients are essential. The purpose of this study was to investigate preventable mortality in trauma patients and to identify factors and healthcare-related challenges affecting mortality. Ultimately, these findings will help to improve the quality of trauma care. Methods: We analyzed the deaths of 411 severe trauma patients who presented to Gachon University Gil Hospital regional trauma center in South Korea from January 2015 to December 2017, using an expert panel review. Results: The preventable death rate of trauma patients treated at the Gachon University Gil Hospital regional trauma center was 8.0%. Of these, definitely preventable deaths comprised 0.5% and potentially preventable deaths 7.5%. The leading cause of death in trauma patients was traumatic brain injury. Treatment errors most commonly occurred in the intensive care unit (ICU). The most frequent management error was delayed treatment of bleeding. Conclusions: Most errors in the treatment of trauma patients occurred in early stages of the treatment process and in the ICU. By identifying the main causes of preventable death and errors during the course of treatment, our research will help to reduce the preventable death rate. Appropriate trauma care systems and ongoing education are also needed to reduce preventable deaths from trauma.

호흡 동조 췌장 암 용적 세기조절 회전 치료 시 Inter-fraction Intra-fraction 분석 (Analysis of inter-fraction and intra-fraction errors during volumetric modulated arc therapy in Pancreas Ca)

  • 조영필;서동린;홍택균;강태영;백금문;홍동기;윤인하;김진산
    • 대한방사선치료학회지
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    • 제26권2호
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    • pp.247-256
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    • 2014
  • 목 적 : 췌장 환자 방사선 치료 중 기점(Fiducial) 대상 내부 및 외부 종양 움직임의 오차를 정량화 하고자 한다. 또한 cone beam computed tomography (CBCT) 를 기반으로 호흡 시 췌장의 움직임 분석하고자 한다. 대상 및 방법 : 용적 세기변조 회전조사 (V-MAT)를 적용, 정위적 방사선 치료를 국소 진행성 췌장암 환자 11명을 대상으로 하였다. CBCT 및 직교 투시이미지를 적용하여 기점(Fiducial Marker)의 Inter, intra-fraction 움직임 변화를 치료 전, 치료 진행 시 분석하였다. 결 과 : 치료 후 프로토콜을 오프라인 교정 프로토콜을 사용하여, CBCT 와 직교투시 간의 평균 오차(범위)는 0.0(-1.7~4.0), 0.3(-0.5~3.0) and 0.0(-4.1~6.6)mm 측방 (LR), 세로 (AP) 및 종 방향 (SI) 이였다. 무작위 Inter-fraction Setup 오차 결과는 -0.1, -2.3 and -1.1 mm: 95% Fiducial포함 마진은 각 9.9, 7.8, 12.5mm로 수식되었다. 결 론 : 위 분석으로 뼈 일치 정렬 후 잔류 불확실성이 있으며, SI 방향에 큰 임의의 움직임은 적합한 여백이 필요하다. 주변 내부 장기를 보호, 내부 장기 문제점을 최소화, 호흡편차를 고려, 치료 시 정기적으로 측정하여야 한다.

자궁경부질 도말 검사 정도 관리과정으로서의 세포 및 조직진단의 비교 분석과 10% 무작위 재선별과의 비교 분석 (Quality Improvement Methods in Cervico-vaginal Cytology; Cytologic/Histologic Correlation vs. 10% Random Rescreening)

  • 윤길숙;허주령;손경희;김온자;공경엽
    • 대한세포병리학회지
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    • 제9권2호
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    • pp.129-137
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    • 1998
  • Although the success of the Papanicolaou test as a screening tool of cervical cancer is evident, there still exists $2{\sim}5%$ of discrepancy rate by both human and machine. To improve the qualilty of cervico-vaginal cytology, the authors compared cervicovaginal smear with cervical biopsy diagnoses, and analysed the causes of discrepancies. Among 30,922 cervicovaginal smears from June 1996 to April 1997 at our hospital, there were 271 cases of cervicovaginal smear with subsequent cervical punch or LEEP cone biopsies within several months. The biopsies and smears from a total of 98 discordant cases were reviewed. The discrepancy was attributed to sampling errors in 43 cases(43.9%), and to cytologic diagnosis in 49 cases(50.0%). Among these, 43 cases were interpretative errors(categories A;19, B;16 and C;8) whereas six cases were screening errors(categories B:2 and C:4). Among cervical biopsy cases, errors were present in four. As for 10% random rescreening, cytotechnologists reviewed 3,196 of 30,922 smears during the same period, There were 43 cases of screening error(categories A;27, B;16). Cytologic/histologic correlation was superior to 10% random rescreening of negative cases. The most effective method for quality improvement in cervicovaginal cytology was to implement both quality control(rescreening) and qualify assurance(cytologic/histologic correlation) programs.

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서비스 분야에서 인간공학과 인적오류 연구 (Human Errors and Human Factors in Service Delivery Processes: A Literature Review and Future Works)

  • 홍승권
    • 대한인간공학회지
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    • 제30권1호
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    • pp.169-177
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    • 2011
  • The aim of this study is to review previous studies on human errors in the service delivery processes. Service industry is sharply growing in the advanced countries. Many people are looking for something to contribute to the service industry. Although there are many research topics related to service domain that human factors and ergonomics specialists can do contribute, a few researchers are studying such topics. This paper indicated how previous researches on human factors and human errors have addressed the service domain, in order to prompt human factor study on the service domain. A variety of sources were inspected for literature reviews, including books and journals of managements, medicine, psychology, consumer behavior as well as human factor and ergonomics. The characteristics of human errors in the service domain were investigated. Human error studies in several service sectors were summarized such as medical service, automotive service operation, travel agent service and call center service. Until now, human factors community was not much interested in human errors in service domain. However, there is much space to contribute to service domain; human error identification, human error analysis and control of human error. The research of human error in service domain can provide clues to improve service quality. This paper helps to guide to identify human error of service domain and to design service systems.

"맥경(脈經)"."맥결(脈訣)"."맥결간오(脈訣刊誤)"의 비교를 통한 "맥결(脈訣)"의 맥상(脈象)에 대한 연구(硏究) (Study on the definitions of pulses of "Maekgyeol(脈訣)" by comparison of "Maekgyung(脈經)" and "Maekgyeol(脈訣)" and "Maekgyeolganoh(脈訣刊誤)")

  • 정치욱;윤창열
    • 대한한의학원전학회지
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    • 제23권5호
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    • pp.103-116
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    • 2010
  • "Maekgyung(脈經)" was the first book for diagnostic method in traditional Chinese medicine history, but it couldn't be spreaded widely. After that, "Maekgyeol(脈訣)" was widely spreaded for centuries, because it was more concise and easier to memorize than "Maekgyung". But as time went by, people got to know that "Maekgyeol" had many errors. After "Maekgyeolganoh(脈訣刊誤)" corrected the errors of "Maekgyeol", "Maekgyeol" came to lose its reputation and people began to study "Binhomaekhak(瀕湖脈學)" instead of "Maekgyeol". We got to wonder why "Maekgyeol" was criticized by many people, so we decided to compare the definitions of pulses(脈象) in "Maekgyung" and "Maekgyeol" and "Maekgyeolganoh". Both "Maekgyung" and "Maekgyeol" have 24 kinds of pulses, but 22 kinds are in common. In 22 kinds of pulses, only 2 kinds of definitions are similar and the others are different. And "Maekgyeolganoh" criticized errors of "Maekgyeol" and corrected the definitions by that of "Maekgyung". In conclusion, we come to know that "Maekgyeol" was rejected by people because it defined most of pulses different from "Maekgyung".

Analysis of Statistical Methods and Errors in the Articles Published in the Korean Journal of Pain

  • Yim, Kyoung-Hoon;Nahm, Francis Sahn-Gun;Han, Kyoung-Ah;Park, Soo-Young
    • The Korean Journal of Pain
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    • 제23권1호
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    • pp.35-41
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    • 2010
  • Background: Statistical analysis is essential in regard to obtaining objective reliability for medical research. However, medical researchers do not have enough statistical knowledge to properly analyze their study data. To help understand and potentially alleviate this problem, we have analyzed the statistical methods and errors of articles published in the Korean Journal of Pain (KJP), with the intention to improve the statistical quality of the journal. Methods: All the articles, except case reports and editorials, published from 2004 to 2008 in the KJP were reviewed. The types of applied statistical methods and errors in the articles were evaluated. Results: One hundred and thirty-nine original articles were reviewed. Inferential statistics and descriptive statistics were used in 119 papers and 20 papers, respectively. Only 20.9% of the papers were free from statistical errors. The most commonly adopted statistical method was the t-test (21.0%) followed by the chi-square test (15.9%). Errors of omission were encountered 101 times in 70 papers. Among the errors of omission, "no statistics used even though statistical methods were required" was the most common (40.6%). The errors of commission were encountered 165 times in 86 papers, among which "parametric inference for nonparametric data" was the most common (33.9%). Conclusions: We found various types of statistical errors in the articles published in the KJP. This suggests that meticulous attention should be given not only in the applying statistical procedures but also in the reviewing process to improve the value of the article.

토모테라피 치료 시 Bodyfix System에서 진공압박에 따른 환자 위치잡이오차(Setup errors)의 평가 (Evaluation of Setup Errors for Tomotherapy Using Differently Applied Vacuum Compression with the Bodyfix Immobilization System)

  • 정재홍;조광환;이정우;김민주;임광채;문성권;김용호;서태석
    • 한국의학물리학회지:의학물리
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    • 제22권2호
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    • pp.72-78
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    • 2011
  • 본 연구의 목적은 토모테라피(Hi-ArtII, TomoTherapy, USA) 치료 시 Bodyfix system (Medical Intelligence, Ele-kta, Schwabmuchen, Germany)에서 진공압박(Vacuum compression)에 따라 환자 위치잡이오차(Patient's setup-errors)를 평가하고자 하였다. Bodyfix system와 진공압박을 적용한 토모테라피를 이용하여 치료를 시행한 흉복부 환자 21명을 선정하였으며, 모든 환자는 치료 전 촬영된 총 477개의 메가볼테이지 전산화단층촬영(Mega-voltage computed tomography, MVCT)영상을 얻었다. 이를 통하여 확인된 좌우방향(Medial-Lateral direction, ML), 앞뒤방향(Anterior-Posterior direction, AP), 상하방향(Superior-Inferior direction, SI)과 SI중심축 회전각(Rotational angle of SI axis direction, Roll)에 대한 오차를 기록하고, 분석하였다. 세 방향 및 Roll에 대한 상관관계와 진공압박 정도가 다르게 적용된 다섯 그룹에 대하여 setup-errors를 분석하기 위해 각각 Pearson's product-moment coefficient와 One-way ANOVA를 이용하여 통계적으로 분석하였다(p<0.05). 분석결과 Systematic errors의 평균은 AP에서 6.00 mm, 표준편차는 SI에서 5.95 mm로 큰 오차를 보였다. Random errors의 평균은 SI방향에서 4.72 mm로 큰 오차가 발생하였다. 관계분석에서는 상관계수가 ML-Roll과 AP-Vector는 0.485, 0.244이고, SI-Vector에서 관계가 제일 높았다(0.637). 또한, 진공압박 정도가 다르게 적용된 다섯 그룹(Pressure range: 30~70 mbar) 사이의 setup errors를 분석한 결과 ML, SI방향과 Roll에서 모두 p=0.00 (p<0.05)로써 유의한 차이를 보였으며, SI방향에서 진공압박에 따른 오차 평균은 40 mbar과 70 mbar그룹에서 4.78 mm, -0.74 mm였다. 본 연구에서는 진공압박과 setup-errors의 평가를 통계적으로 분석하였으며, 압박 정도에 따라 SI방향에서 setup-errors의 차이를 확인하였다. 최종적으로 setup-errors와 내부장기의 움직임을 고려하자면 Bodyfix system을 이용한 진공압박을 적용시 최소 50 mbar 이상을 사용해야 할 것이다. 본 연구결과를 토대로 진공압박의 정확성과 내부장기 및 종양의 움직임을 정량적으로 분석할 필요가 있다고 판단된다.

선천성 대사 이상 질환에서의 골격계 증상 발현 (Skeletal Manifestations of Inborn Errors of Metabolism: A Comprehensive Retrospect)

  • 조성윤
    • 대한유전성대사질환학회지
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    • 제23권1호
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    • pp.1-11
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    • 2023
  • Inborn errors of metabolism encompass a wide variety of disorders, frequently affecting bone. This review presents a comprehensive retrospect on the primary involvement of bone in inborn errors of metabolism. Primary involvement of bone in inborn errors of metabolism includes entities that primarily affect the bone marrow, mineral component or cartilage. These include lysosomal storage disorders, hypophosphatasia, and hereditary hypophosphatemic rickets. In this review, we discuss the primary involvement of bone in inborn errors of metabolism (hypophosphatasia, X-linked hypophosphatemic rickets, Gaucher disease, and mucopolysaccharidoses) along with the therapeutic agents used in clinical settings, diagnostic strategies, and general management. With the development of disease-specific targeted therapies and supportive care, more number of patients with these disorders live longer and survive into adulthood. Moreover, skeletal symptoms have become a more prominent feature of these disorders. This makes the awareness of these skeletal symptoms more important.

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