• Journal of Korean Academy of Nursing
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• v.49 no.5
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• pp.631-642
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• 2019

Purpose: This study aimed to predict the influencing factors and the consequences of near miss in nurses' medication error based upon Salazar & Primomo's ecological system theory. Methods: A convenience sample of 198 nurses was recruited for the cross-sectional survey design. Data were collected from July to September 2016. Using the collected data, the developed model was verified by structural equation modeling analysis using SPSS and AMOS program. Results: For the fitness of the hypothetical model, the results showed that $x^2$ ($x^2=258.50$, p<.001) was not fit, but standardized $x^2$ ($x^2/df=2.35$) was a good fit for this model. Additionally, absolute fit index RMR=.06, RMSEA=.08, GFI=.86, AGFI=.81 reached the recommended level, but the Incremental fit index TLI=.82, CFI=.85 was not enough to reach to the recommended level. With the path diagram of the hypothetical model, caution (${\beta}=-.29$ p<.001), patient safety culture (${\beta}=-.20$, p=.041), and work load (${\beta}=.18$, p=.037) had a significant effect on the near miss experiences in nurses' medication error, while fatigue (${\beta}=-.06$, p=.575) did not affect it. Moreover, the near miss experience had a significant effect on work productivity (${\beta}=-.25$, p=.001). Conclusion: These results have shown that to decrease the near miss experience by nurses and increase their work productivity in hospital environments would require both personal and organizational effort.

• Quality Improvement in Health Care
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• v.22 no.1
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• pp.41-57
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• 2016

Objectives: This study aimed to investigate how many healthcare professionals experienced near misses, what types of near misses occurred most often, and healthcare professionals' opinions about near misses at one university hospital in Korea. Methods: The authors developed a questionnaire including 26 core types of near misses and 4 questions about preventability and reporting barriers. The survey was conducted from Oct. 31st to Nov. 18th 2011, about 3 weeks, using a self-administrated questionnaire that was administered to 697 healthcare professionals (registered nurses, pharmacists, technicians, and nurses aides) who worked at a university hospital. Medical doctors and employees working in the department of administration were excluded. Results: About half of hospital workers experienced at least one or more near misses during the past one year. The drug dispensing process was the most common subcategory of near misses. Among the 26 items, patient falls was highest. Over 95% of respondents reported that the near miss they experienced was preventable. Also, more than half of respondents did not report the near miss and the main reason for omission was fear of blame. Conclusion: Regarding patient safety issues, a near miss is a very significant factor because it can be a potential adverse event. Therefore, we should grasp the size of the problem through tracking and analyzing near misses and should make an effort to reduce them. To do so, we should check whether our reporting system is well designed and functioning.

• Transactions of the Korean Society of Mechanical Engineers A
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• v.38 no.12
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• pp.1325-1333
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• 2014

The dispersion pattern of a near miss neutralizer has a great effect on the disablement of a threatening projectile. This study numerically investigated the dispersion pattern of cylindrical tungsten impactors by an explosion in the near miss neutralizer. The mass and shape of the explosive were considered as influencing factors on the dispersion pattern. The explosives were set using two shape models: a parallel shape with the same upper and lower thicknesses and a tapered shape with different upper and lower thicknesses. In the simulation results, the dispersed impactors formed a ring-shaped pattern on a two-dimensional plane in an arbitrary space. In addition, the fire net area increased with the explosive mass when the explosive shapes were identical. In particular, the tapered shape explosive formed a larger fire net area than the parallel shape explosive. Based on the analysis of the fire net area along with the dispersion density, both the explosive mass and shape representing the physical characteristics should be considered for controlling the dispersion pattern of impactors in a near miss neutralizer.

• Progress in Medical Physics
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• v.27 no.3
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• pp.131-138
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• 2016

We analyzed the terminology and classification related to the risk management of radiation treatment overseas to establish the terminology and classification system for Korea. This study investigated the terminology and classification for radiotherapy risk management through overseas research materials from related organizations and associations, including the IAEA, WHO, British group, EC, and AAPM. Overseas risk management commonly uses the terms "near miss", "incident", and "adverse event", classified according to the degree of severity. However, several organizations have ambiguous terminologies. They use the term "near miss" for events such as a near event, close call, and good catch; the term "incident" for an event; and the term "adverse event" for the likes of an accident and an event. In addition, different organizations use different classifications: a "near miss" is generally classified as "incident" in most cases but not classified as such in BIR et al. Confusion might also be caused by the disunity of the terminology and classification, and by the ambiguity of definitions. Patient safety management of medical institutions in Korea uses the terms "near miss", "adverse event", and "sentinel event", which it classifies into eight levels according to the severity of risk to the patient. Therefore, the terminology and classification for radiotherapy risk management based on the patient safety management of medical institutions in Korea will help in improving the safety and quality of radiotherapy.

• Proceedings of the Korean Institute of Navigation and Port Research Conference
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• 2011.06a
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• pp.170-172
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• 2011

최근 ATLAS사(社)의 VTS 시스템에 통항분석 프로그램이 도입되었다. 통항분석 프로그램을 소개하고 이를 통한 통항량 및 통항 패턴분석과 Ship Near Miss, 선속에 따른 패턴을 분석하였다. 프로그램을 사용하면서 사용자입장에서 느낀 장 단점을 정리하고 개선방향에 대하여 정리하였다.

• Journal of the Korean Society for Aviation and Aeronautics
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• v.20 no.4
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• pp.84-90
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• 2012

Aviation Maintenance Technician(AMT)'s error is not directly link to deficiency which is differ to flight crew's error and it potentially maintains. Due to it usually occur as undesired aircraft state, hazards, like unreported maintenance error or near miss fortunately undetected and are not develop to accident. This could be a crucial influence of an accident occurrence. To remove these hazards, just safety culture should be support that anyone can report about safety problems and person who reported safety problems and hazards like near miss, should not get disadvantages. Also if it is satisfied, they must exempt for punishment and guaranteed for security. Hence, on this study, aviation maintenance site's just culture need to be researched and analysed about improvement for aviation maintenance field's positive just culture.

• Explosives and Blasting
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• v.15 no.1
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• pp.26-35
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• 1997

The research on the safe and efficient demolition technique of building structure is required due to rapid increase in structures which has the problems of safety and endurance. The techniques of blasting and operation and parameters affecting the efficiency of demolition were analyzed to maximize demolition efficiency. And successful, unsuccessful and near-miss demolition cases in Korea have been investigated so that demolition operation can be safe and accurate.

• Journal of the Korea Safety Management & Science
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• v.8 no.2
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• pp.13-23
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• 2006

The present study has investigated the patterns and the causes of safety -accidents on the accident-data in semiconductor Industries through near miss report the cases in the advanced companies. The ratio of incomplete actions to incomplete state was 4 to 6 as the cases of accidents in semiconductor industries in the respect of Human-ware, Hard- ware, Environment-ware and System-ware. The ratio of Human to machine in the attributes of semiconductor accident was 4 to 1. The study also investigated correlation among the system related to production, accident, losses and time. In semiconductor industry, we found that pattern of safety-accident analysis is organized potential, interaction, complexity, medium. Therefore, this study find out that semiconductor model consists of organization, individual, task, machine, environment and system.

• ETRI Journal
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• v.45 no.6
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• pp.1007-1021
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• 2023

Stroke is the leading cause of permanent disability in adults, and it can cause permanent brain damage. According to the World Health Organization, 795 000 Americans experience a new or recurrent stroke each year. Early detection of medical disorders, for example, strokes, can minimize the disabling effects. Thus, in this paper, we consider various risk factors that contribute to the occurrence of stoke and machine learning algorithms, for example, the decision tree, random forest, and naive Bayes algorithms, on patient characteristics survey data to achieve high prediction accuracy. We also consider the semisupervised self-training technique to predict the risk of stroke. We then consider the near-miss undersampling technique, which can select only instances in larger classes with the smaller class instances. Experimental results demonstrate that the proposed method obtains an accuracy of approximately 98.83% at low cost, which is significantly higher and more reliable compared with the compared techniques.

• Proceedings of KOSOMES biannual meeting
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• 2017.11a
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• pp.117-117
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• 2017