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The Effects of Near Miss and Accident Prevention Activities and the Culture of Patient Safety Management for the Patient Safety (Near Miss 사고 예방 활동과 환자안전관리 문화형성이 환자안전에 미치는 영향)

  • Chang, Ho-Suk;Lee, Gui-Won
    • The Korean Journal of Nuclear Medicine Technology
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    • v.14 no.2
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    • pp.138-144
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    • 2010
  • Purpose: Despite the rapidly changing healthcare environment, healthcare organizations have recognized the importance of patient safety management. But patient safety management has the problem of the lack of participation of members due to the process of focusing on the follow-up service and punishment. The department of nuclear medicine in Uijeongbu St. Mary's Hospital started this research to reduce the near miss and prevent patient safety accidents by both initiating the participatory near-miss-proof activities as an advance management and constructing a system without disadvantages of reporting. In addition, this research aims to establish a differentiated patient safety management system in the department of nuclear medicine. Materials and Methods: 1. Colleting cases of team members' past and present near miss and accidents(First data collection). 2. Quantifying the cases of near miss and accidents after identifying the degree of importance and urgency through surveys(Second data collection). 3. Quantifying cases and indentifying important points of contact through data analysis. 4. Making and standardizing a manual for important points of contact, and initiating participatory activities to prevent errors. 5. Activating web-based community for establishing the report system of near miss. 6. Estimating the result of before and after activities through surveys and focus group interviews. Results: 1) Quantified safety accidents and near miss in the department of nuclear medicine. About 50 near misses a month and one safety accident a year. 2) Establishing improvement measurements based on quantified data. About 11 participatory activities, the improvement of process, a manual for standardization. 3) Creating a system of safety culture and high participation rate of team members. Constructing a report system, making a check list and a slogan for safety culture, and establishing assessment index. 4) Activating communities for sharing the information of cases of near misses and accidents. 5) As the result of activities, the rate of near miss occurrence declined by 50% and the safety accident did not happen. Conclusion: The best service in the department of nuclear medicine is to provide patients with safety-guaranteed high-quality examination and cure. This research started from the question, 'what is the most faithful-to-the-basics way to provide the best service for patients?' and team members' common answer for this question was building a system with participation of all members. Building a system through the participatory improvement activities for preventing near miss and creating safety culture resulted in the 50% decline of near miss occurrence and no accident. This is a meaningful result from the perspective of advance management for patient safety. Moreover, this research paved the way for creating a culture to report and admit near miss or accidents by establishing a report system with no disadvantage of reporting. The system which sticks to the basics is the best service for patients and will form a patient safety culture system, which will lead to the customer satisfaction. Therefore, all members of the department of nuclear medicine will develop a differentiated patient safety culture with stabilizing the established system.

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A Study on the Mechanical and Physical Properties of Sawdustboard combined with Plastic Chip (플라스틱칩 결체(結締) 톱밥보드의 기계적(機械的) 및 물리적(物理的) 성질(性質)에 관(關)한 연구(硏究))

  • Lee, Phil-Woo;Suh, Jin-Suk
    • Journal of the Korean Wood Science and Technology
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    • v.15 no.3
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    • pp.44-55
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    • 1987
  • In order to study the effect of sawdustboard combined with plastic chips, 0.5mm($T_1$), 1mm($T_2$), 1.4mm($T_3$) thick nylon fiber. polypropylene rope fiber(RP), and 0.23mm thick moth-proof polypropylene net fiber(NP) were cut into 0.5, 1, 2cm long plastic chips. Thereafter, sawdustboard combined with plastic chips prepared as the above and plastic non-combined sawdustboard(control) were manufactured into 3 types of one-, two-, and three layer with 5 or 10% combination level. By the discussions and results at this study, the significant conclusions of mechanical and physical properties were summarized as follows: 1. The MORs were shown in the order of 3 layer> 2 layer> 1 layer among plastic non-combined boards, and $T_3$ < $T_2$ < $T_1$ < RP (NP(5%) < NP(l0%) among plastic combined boards. In 2cm long plastic chip in 1 layer board, the highest strength through all the composition was recognized. 1 layer board showing the lower strength with 0.5cm plastic chip rendered to the bending strength improvement by 2 or 3 layer board composition. On the other hand, 2 or 3 layer combined with 1, 2cm long polypropylene net fiber chips incurred MOR's conspicuous decrease requiring optimum plastic chip combined level and consideration to combined type. 2. MOE in plastic non-combined 3 layer board exhibited sandwich construction effect by higher resin content application to surface layer in the order of 3layer>1layer>2layer with the highest stiffness of the board combined with polypropylene chip, while nylon chip-combined board had little difference from plastic non-combined board. In relevant to length and layer effect, 3 layer board combined with the 0.5cm long polypropylene net fiber chip in 5% and 10% combined level presented 34-43% and 44-76% stiffness increase against plastic non-combined board(control), respectively. Moreover, in 1 layer board, 30% stiffness increase with 10% against 5% combined level in the 1 and 2cm long polypropylene net fiber chip was obtained. 3. Stress at proportional limit(Spl) showing the fiber relationship (r: 0.81-0.97) between MOR presented in the order of 1 layer<2 layer<3 layer in plastic non-combined board. Correspondingly, combined effect by layer and plastic chip length was similar to MOR's. 4. Differently from previous properties(MOR, MOE, Spl). work to maximum load(Wml) of 2 layer board approached to that of 3 layer board. Conforming the above phenomenon. 2 layer combined with 0.5cm long polypropylene net fiber chip kept the greater work than 1 layer. The polypropylene combined board superior to nylon -and plastic non - combined board seemed to have greater anti - failing capacity. 5. Internal bond strength(IB), in contrast to MOR's tendency. showed in the order of T1

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The Effects of A Cognitive-Behavioral Anger Control Training on Anger Control Ability and Peer Relationships of Children (인지행동적 분노조절 훈련이 아동의 분노조절능력과 교우관계에 미치는 효과)

  • Kim, Mi-Ra;Lee, Young-Man
    • The Korean Journal of Elementary Counseling
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    • v.7 no.2
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    • pp.101-115
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    • 2008
  • The purposes of this study were to consist an anger control program in order to help children confirm and modify their cognitive errors in peer anger-provoking situations(Lee Mi-gyeong, 2006), that and to examine the effects of this program on anger-provoking experience, anger controllability and peer relationship. The cognitive-behavioral anger control program was consisted of 16 sessions. The focus of the program were placed on perceiving angry feelings, confirming automatic thinking and cognitive errors and acquiring how to correct the cognitive errors(1st-10th sessions), and checking cognitive errors in 13 anger-provoking situations and practicing way to correct the errors(11th-15th sessions). To examine the effects of the program, 10 children who had a lot of anger-provoking experiences, and were poor at anger control and faced difficulties with peer relationship were selected. The cognitive-behavioral anger control program was implemented for eight weeks, twice a week, 40 minutes each. The collected data were analysed by the ANOVA method using the SPSS and Kwakstat(Kwak Ho-wan, 1993). What cognitive errors children made and how they modified the errors during the program were checked. The findings of the study were as follows: The cognitive-behavioral anger control program served to cut down on the anger-provoking experiences, to improve their anger controllability, to boost their peer relationship, and that effect lasted till six weeks later. And the cognitive errors they made during the program were in the order as follows: stating the oughtness of their behavior, followed by naming, seeing everything in black and white, emotional judgment, mind reading, linking the situation to themselves, overgeneralizing, and hasty conclusion. The ways to correct the cognitive errors were in the order as follows: putting oneself in another's place, explaining in a different manner, looking for proof, thinking of it is so difficult to indure, thinging of there is moral to it, and thinking of how angry after passing time.

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A Study on the form of korean Women's Hair Style-From the Viewpoint of Woman's Hair Style in Cho-Sun Dynasty- (한국 여성의 수발양식 관한 연구 -조선시대 여성 수발법을 중심으로-)

  • 정상숙;조효순
    • Journal of the Korean Society of Costume
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    • v.41
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    • pp.95-105
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    • 1998
  • SOO-BAL(Hair Style) is a method Which match hair style to face and clothes with using hair covering and protecting the head. Also SOO-BAL includes personal ornaments using to avoid one's hair be disheveled. In a standpoint of beauty and spirit, etiquette SOO-BAL is a very important thing as one being dressed up. Until now, since just a form of hair style have been studied, hair styling process is nothing to be known and studied. Time after time, our unique traditional SOO-BAL is forgotten with clothes and then this th-esis will be classified hair styling form follow-ing a form of hair style in royal palace of the C-hosun dynasty. According to the record of HAE DONG HISTORY, it shows the same of attire between Ko-rean and chinese style in ae of the chosun. The reason in that there were no any certain boundary border and the interaction of culture between two countries was happened spontaneously at ancient time like the GOCHO-SUN age. Until the period of the three states, the korean attire be changed had gone with chinese one s-imilarly. The chinese form gave to influence on the EONJIN MEURI·POON-GI-MYEONG MEURI·JJO-CJIN MEURI·MOOK-EUN GOONG-BAL MEURI·OL-LIN MEURI·SSANGSANG-TU ME-URI be drawn wall painting in the KOKUR-YU. And a gold chignon accesso-ry unearthed in a MOO-RYOUNG royal mausoleum is proof of the korean attrire be changed with chinese. In the shilla dynasty at three years after Cjin-Deuk(A.D. 649) reign. It was recorded that the dynasty let women wear the form of chinese attire. Also in the koryo dyn-asty, a rod-like hairpin (BIN-YEU) and DANG-GI employing EON-JIN MEURI was used. The SOO-BAL based on the Confucianism had lots of regulations which limited to use ornaments with classes of society in the CHOSUN dynasty. Until YOUNG CHO and CHUNG CHO period. EONJIN MEURI be decorated GACHAE was announced by dynasty as ind-ulging in luxury. Women of yangban used a rod-like hairpin and a chignon accessory made by jewerly. And 1-owly women weared a rod-like hairpin made of born and wood to perfom EONJIN MEURI with PUNCHAE. Most unmarried women decorated with DDA-AH-NEULIN MEURI, GUI-MIT MEURI, specially in palace with SAE-ANG MEURI. At palace, one put on a full dress with KEUN MEURI, and a simple dress with ER-YEO MEURI be decorated DDERL-JAM The CHOP-JI MEURI manifested social rank, class. Kids at CHO-SUN age had BA-DUK-PANMEURI and JONG-JONG MEURI. The ornament things are GACHE, DDERL JAM with EON-JIN M-EURI, and all kinds of rod-like hairpin and chignon accessory used in JJOK MEURI. IN DANGGE, JE-BI-BURI DANGGI used by ummarried women. DO-TOO-RAK DANGGI and AP DANGGI on a dress suit, and BE-SSI DANGGI used by 3∼4 years ungrown kids etc. were used. And at palace, kinds of CHUPJI used with JJOK MEURI showed social rank. In CHOSUN age, women want to keep shiny hair washed at TA-NO festival day, a treatment of bald hair used a forked remedy. In CHOSUN age, woman Soo-Bal hair style has DAE-SOO·DDEU-KOO-JI MEURI·CHO-P-GI MEURI·EON-JIN MEURI·SAE-ANG MEURI· and so on. We could find out Soo-Bal was developed very well by these variety hair styles. I attatched all of the hair style pictures step by step, and also explained detail my research foll owing these pictures.

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The costume culture of China is as old and varied as her long history (중국 소수민족의 복식 연구(1))

  • 박춘순
    • Journal of the Korean Society of Costume
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    • v.26
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    • pp.175-206
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    • 1995
  • The costume culture of China is as old and varied as her long history. As China is a multiracial nation and consists of fifty-six min-ority races including Han race, there are not only fifty-six different costumes in China but each races' costume habit is very different. Therefore, Chinese penninsula can be considered an enor-mous exhibition center of the costumes. This study undertook on the assumption that the costumes' mainstream of Korea and east-northern Asia as well as that of China could be examined by investigating the minority races' costumes in the east-and west-northern areas of China. The process of evolution of the costume of a particular people, country or area is subject not only to constraints related to geography such as climate, topography or local products but is also affected by numorous environmental influences including cultural, economic, social and even pol-itical ones in terms of the selection of material, styling, color and standard of tailoring. In other words, things like philosophy of life, religious be-lief, aesthetic outlook, moral code, class system, degree of affluence, and cultural exchange will all be reflected directly or indirectly by features of a people's or country's style costume. Of course, there are several factors affecting to the style of costume of the minority people in China. However, the only three factors-geo-graphical and environmental, production method, and religious belef-will be touched in this study. First of all, the geograghical and eenviron-mental factor would be the decisive one because the costume should be designed to overcome the constraints of climate and geographical environ-ments. Accordingly, each race has an unique style of costume. The costume of the minority races in the northern parts are loose and wide, and made of warm furs. For instance, Mongolian robe has the quality of anti-wind, anti-cold and warmness, and the width of a sleeve is narrow and long. Secondly, the costume style can be said to be limited by the production pattern, when the geo-graphical environment was affected to decide the costume style, the production pattern was together affected to it . In case of Mongolian robe, they should satisfy the dual condition as the practical function. One is the condition that they should be fitted to the climate, and the other is the condition that they should be suit-able to the nomadic life. Mongolian robes are suitable to the nomadic peoples because they are designed for not only overcoming the cold wind and weather but being used as the bedquit at night. The costumes of Hoche people was made of the skin of the fish and wild animals because of their main means of living being fishing and hunting. Accordingly, their costumes are dur-able, warm and water-proof. Finally, the style of the costume is affected by the religious belief. In other words, the pattern in fashion is closely related with the religious be-lief or ancestor worship and nature worship. Ac-cordingly, the symbols of these worship are often emerged in the decoration of the costume. The design of costume of the people in the northern areas of China is very simple. It is related with their monotheism. On the other hand, the costumes of twen쇼 minority races in the east-northern parts of China can be devided into three racial groups such as the long robes of Man people and Mongols, Tunics of the peoples in the west-northern areas, and the pants and jackets of Hoche people. The minorority races all has not only the unique costume habit but their costumes are also related with their living style and production means.

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A Study on the Material Characteristics and Functionality Evaluation of a Size Layer of a Canvas (캔버스 차단층(Size Layer)의 재료특성 및 기능평가 연구)

  • Kim, Hwan Ju;Lee, Hwa Soo;Chung, Yong Jae
    • Journal of Conservation Science
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    • v.32 no.2
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    • pp.167-178
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    • 2016
  • Despite the size layer is an important part for conserving the artworks in the configuration of oil painting, the conservation scientific approaches of that have not been made yet. Therefore, this study produced standard samples on the basis of the analysis results of oil painting works, and carried out the evaluation of functions of the size layer materials. As a result of literature material, traditionally, animal glue was used for the size layer, whereas synthetic resin have been used in combination with animal glue since the modern age, in particular, it was identified that Polyvinyl Acetate(PVAc) was in general use. As a result of analysis of oil painting works, size layer was detected on the support and it was identified as animal glue. As a result of analysis based on Funaoka canvas for ground, it showed that the lead oxide and the titanium dioxide were the main constituents. On the basis of these results, standard samples were produced. As a result of evaluation on the functions of the size layer materials, in the case of the animal glue, stable result was observed in the shrinkag expansion rate, whereas slight weakness was observed in moisture proofing, color, and tensile strength, and dense cracks were found on surface. As for PVAc(A), moisture proofing, color, and the tensile strength exhibited stable results. Higher shrinkage rate was observed and the cracks with wide gaps were found on surface. As for PVAc(B), tensile strength, shrinkage expansion rate, and surface observation showed stable results, whereas moisture proofing property showed poor results. Different aspects were observed in each experiment, and this phenomena were considered to be due to the density and the adhesion properties between the hydrophilic and hydrophobic molecules in the size layer materials. The results are expected to be used as materials for the oil painting work conservation henceforth.

A Study on the Damages of Head Works by the Storm Flood in the Area of Cheong Ju and Boeun -Emphasis onFactors Influenced on the Disasters and their Countermeasures- (淸州 및 報恩地方의 頭首工洪水災害에 關한 調査硏究(II) -災害原因 및 對策方案을 中心으로-)

  • Nam, Seong-Woo;Kim, Choul-Kee
    • Magazine of the Korean Society of Agricultural Engineers
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    • v.24 no.2
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    • pp.49-55
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    • 1982
  • The purpose of this study is to classify the factors influenced on the damages of head works suffered from the storm flood occurred on July 22 1980 in both Musim and Bochong rivers and to find out an integral counter measures against the causes influenced on the disaster of head works in the engineering aspect of planning, design, construction and maintenance. In this survey, number of samples was taken 25 head Works, and the counter measures against the causes of their disasters summarized was as follows, 1. In the aspect of planning a. As the flood water level after the establishment of head works is more increased than the level before setting of head works owing to having more gentle slope of river bed between the head works than nature slope of river bed. Number of head works should be reduced for the appropriate annexation of them b. In the place where head works is established on the curved point of levee, the destruction of levee becomes severe by the strong deflective current. Therefore the setting of head works on the curved point should be kept off as long as possible and in case of unavoidable circumstances the construction method such as reinforced concrete wall or stone wall filed with concrete and anchored bank revetments should be considered. 2. In the aspect of design a. As scoring phenomena at up stream is serious around the weir Where the concentration of strong current is present in such a place, up stream apron having impermeability should be designed to resist and prevent scoring. b. As the length of apron and protected bed is too short to prevent scoring as down stream bed, the design length should be taken somewhat more than the calculated value, but in the case the calculated length becomes too long to be profitable, a device of water cushion should be considered. c. The structure of protected river bed should be improved to make stone mesh bags fixed to apron and to have vinyl mattress laid on river bed together with the improvement for increasing the stability of stone mesh bags and preventing the sucked sand from the river bed. d. As the shortage of cut-off length, especialy in case of the cutoffs conneting both shore sides of river makes the cause of destruction of embankment and weir body, the culculation of cut-off length should be taken enough length based on seepage length. 3. In the aspect of design and constructions a. The overturing destruction of weir by piping action was based on the jet water through cracks at the construction and expansion joints. therefore the expansion joint should be designed and constructed with the insertion of water proof plate and asphalt filling, and the construction joint, with concaved shape structure and steel reinforcement. b. As the wrong design and construction of the weep holes on apron will cause water piping and weir destruction, the design and construction of filter based on the rule of filter should be kept for weep holes. c. The wrong design and construction of bank revetment caused the severe destruction of levee and weir body resulting from scoring and impulse by strong current and formation of water route behind the revetment. Therefore bank revetment should be designod and constructed with stone wall filled with concrete and anchored, or reinforced concrete wall to prevent the formation of water flow route behind the wall and to resist against the scoring and impulse of strong stream. 4. In the aspect of maintenance When the damaged parts occurred at head works the authorities and farmers concerned should find and mend them as soon as possible with mutual cooperation, and on the other hand public citizen should be guided for good use of public property.

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Research on the Loss of Irrigation Water Flowing in the Earth Channel (흙 수로내에서의 용수손실에 관한 연구)

  • 김철회
    • Magazine of the Korean Society of Agricultural Engineers
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    • v.14 no.3
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    • pp.2703-2715
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    • 1972
  • 1. Title of Research Research on the Loss of Irrigation Water Flowing in Earth Channel. 2. Purpose and Importance of Research The purpose of this research is to obtain the accurate loss rated of irrigation water flowing in earth channels so as to give a criterion of designing rational and effective suplpy project of irrigations water. It is the present status that the loss rates of 10 to 20% are obscurely applied without any scientific proof. Therefore, the importance of this research lies in securing loss rates, which are experimentally proves to be suitable for specific local conditions. 3. Content and Scope of Research The selected test reach of the main channel is 1,000m long. Discharges were measured at up and downstream enps by using current meter. The test reach of the lateral channel is 500m long, and parshall flumes were set at both ends to measure inflow and outflow. Finally, for the supply ditch, the test section is 200m long, and sharp-edged rectangular weirs were provided at both ends to measure inflow and outflow. In addition, various factors influence on the loss of irrigation water in channel wer examined. 4. Results of Research and Proposition Results: 1. In the main channel, which is 1,000 M long, and has a slope of 1/3,000 and was constructed by cutting earth, its loss rate is 9.64%. 2. In the lateral, which has a slope of 1/1,500, and is 500m long, and was constructed by cutting, its loss rate is 15.55%. Its average seepage rate is 2.08cm/day. 3. In the supply ditch, which has a slope of 1/300, and is 200m long, and was constructed by filling earth, its loss rate is 12.34%, its average seepage rate being 3.37cm/day. Proposition: As could be seen in the results above-mentioned, it is contradictory to apply a loss rate of 20% for every main channels and 15% for every laterals without variation, as done so for in planning irrigation project. The fact, however, is that loss rates must be different according to localities and characteristics. Due to the fact that this experiment is small in its scope and is nothing but a preliminary one, it is hardly possible to draw decisive conclusions with the results obtained in this research. Loss rates, that are secured through more extensive research, should be used, in order to establish precise irrigation project. Moreover, such researches should be carried out for a number of loclities throughout the nation.

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The Characteristic of the Carrier's Liability Due to the Illegal Act of the Crew during International Air Transportation (국제항공운송 과정에서의 기장 등의 직무상 불법행위에 기한 운송인의 손해배상책임이 가지는 특수성)

  • Kim, Min-Seok
    • The Korean Journal of Air & Space Law and Policy
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    • v.35 no.3
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    • pp.3-37
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    • 2020
  • The aircraft crew operating on international routes performs almost identical tasks as police officials in terms of dealing with the unlawful interference in the aircraft. This means that the liability question which is related to the law enforcement by the police officer may arise regarding the crew's performance of his or her duties. With regard to the carrier's liability due to the crew's unlawful action, there are distinctive characteristics from the liability due to police officers' unlawful action. In case of the claim for damages by the crew's unlawful action, the first question should be whether such action complies with the requirements under the Tokyo Convention 1963. If such action does not conform with the Tokyo Convention 1963, we should examine that claim under the State Compensation Act, the Montreal Convention 1999, and the Civil Act of Korea. The examination under the Tokyo Convention 1963 is not so different from the Korean Court's precedents. However, the court should consider the characteristics of the environment surrounding the crew. The action which is not indemnified under the Tokyo Convention 1963 should be examined under the tort laws. Because the aircraft crew is private persons entrusted with public duties under Korean Law, the State Compensation Act may apply. However, further studies regarding the harmonious interpretation with the Montreal Convention 1999 is needed. With regard to the carrier's liability, the Montreal Convention of 1999 should be applied to the crew's unlawful actions onboard. This is because the Montreal Convention of 1999 preempts the national law for the events that occurred during transportation, and there is no provision which excludes such unlawful actions from the scope of its application. On the other hand, the national law, such as the Civil Act of Korea, applies to unlawful actions taken after transportation. This is because the interpretation that infinitely expands the scope of the Montreal Convention 1999 should not be allowed. Given the foregoing, the standard of the claim for damages due to the crew's unlawful action varies depending on the place where the specific action was taken. As a result, the type of damage recoverable and the burden of proof also varies accordingly. Carriers and crew members must perform their duties with this in mind, but in particular, they should observe the proportionality, and when interpreting the law, it is necessary for the court or lawyer to consider the special characteristics of the work environment.

A study on the Effect of Export Support Policy to Export Performance: Focusing on Small-Medium Start-up Enterprises in Gyeonggi Area (수출역량강화사업이 수출성과에 미치는 효과연구: 경기지역 창업 중소기업을 중심으로)

  • Lee, In Seong;Park, Woo Jin
    • Asia-Pacific Journal of Business Venturing and Entrepreneurship
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    • v.11 no.5
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    • pp.141-151
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    • 2016
  • The purpose of this study is to analyze the effects of the international marketing program (hereunder refer to as 'program') among the programs to support export conducted by the Small and Medium Business Administration. Especially, this study aims to analyze the effects of the program to increase in export for small - medium enterprises of less than 7 years (base on Item 2 of Article 2 of Act on Support for Small and Medium Enterprise Establishment). In order to achieve the purpose above, export result for 1,690 companies which participated through Gyeonggi District Small and Medium Business Administration in 2014 and 2015 were selected among the 843 companies that applied to the program through 12 local small and medium business administration in Korea and quantitative analysis on export performance of 1,690 companies is conducted in this study. In this study, main variables were selected by investigating advanced researches related to export performance of company based on the existing studies. And also, samples have been collected from companies in Gyeonggi area for this research since the companies in Gyeonggi area have been ranked as the 1s annually and the companies in Gyeonggi area employ the highest number of people per industry. As a result of actual proof analysis, Firstly, it was suggested that the program influences positively on the export performance of small-medium enterprises. Secondly, the program shows that the program influenced positively on the export performance of companies with less than 7 years. Lastly, it suggested that the program influenced more positively on the small - medium enterprises with less than 7years than normal small - medium enterprises. By adding the export performances of companies in Ulsan area of which the scale of import and export is the 2nd largest and companies in Seoul area, that participated in the program during the same period, I would like to conduct follow- up research if the significant results are obtained or not.

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