응급실내 의료오류 보고체계의 시범적 운영

안기옥,정진희,어은경,전영진,정구영 대한응급의학회 2007 大韓應急醫學會誌 Vol.18 No.3

Purpose: We have evaluated type of medical errors and severity of results in the emergency department (ED). We also analyze the contributory factors of medical errors for the patient’s safety and the quality improvement. Methods: This study the was prospectively performed from May to August 2005. Medical errors that occurred in the ED were reported anonymously by emergency physicians. The type of medical errors and contributory factors were reported. The severity levels of errors were categorized into 5 levels: level 1- life threatening consequences; level 2- potentially life or limbs threatening consequences; level 3- serious failure or delay of diagnosis or treatment; level 4- inappropriate or unnecessary delay or treatment; level 5- no harm. Results: The total number of patients admitted in the ED during the study period was 16,513, and 177 errors (1.5 errors/day) reported in 160 patients (9.7/1,000 patients). The most frequently occurring medical error was order omission (18.0%), but interpretation errors (11.3%) resulted in the most serious consequences (3.6±1.2). More than half of medical errors were no harm (51.4%). Educational and environmental (61 errors) factors were the most frequent causes of medical errors. Conclusion: Medical errors frequently occur in the ED. Reducing ED errors will require the improvement of ED environments, better communication, and reinforcement of education by supervising faculty members.

의료오류(Medical Error) 공개에 대한 의학전문대학원생과 인턴의 인식 및 태도 비교

이수현,신영혜,김성수 한국의학교육학회 2012 Korean journal of medical education Vol.24 No.3

Purpose:The purpose of this study was to compare attitudes toward disclosing medical errors between medical students and interns. Methods:The questionnaires were administrated to 164 medical students and interns. The questionnaires consist of 3 major concepts: knowledge, attitudes toward disclosure of medical error, barriers to the disclosure of medical error. Results:Interns (56.1%) took medical errors less seriously than medical students (74.8%). Medical students (75.6%) believed that patients would want to be informed of any kind of medical errors while Interns (46.3%) thought so. Medical students (83.1%) considered that serious medical errors should be disclosed to patients. On the contrary, only 46.3% of interns believed so. Medical students (16.3%) and interns (19.5%) believed disclosing medical error would increase patients trust in doctors. Both medical students and interns pointed out worries about malpractice suits as the biggest barrier to disclosing medical error. Conclusion:The attitudes toward disclosing medical error between medical students and interns were significantly different in many aspects. Interns show more negative attitudes about disclosing medical errors than medical students. And they also take medical errors less seriously than medical students. In particular, the attitudes of the subjects in this study were greatly different from the results of a previous patients' attitudes study. These perspectives differences could work against achieving patient-centered care which is the upmost priority in the current trends in health care. The efforts to bridge these perspective gaps between patients and doctors should start from medical school by teaching medical students the importance of the disclosing medical errors.

약물사용과정에서의 환자 안전관리: 의약품사용과오의 예방과 관리

구본기 대한의사협회 2012 대한의사협회지 Vol.55 No.9

Medication errors, resulting in risks to patient safety, occur throughout the entire medication use process, and include prescribing errors, dispensing errors, administering errors, and patient compliance errors. The results of many reports and studies on medication errors in several countries including the United States show that medication errors occur commonly, are costly and are often preventable. Medication errors involve a breakdown in more than one aspect of the medication use system such as lack of knowledge, standard performance and mental lapses,and defects or failure in the organizational system. Such medication errors compromise patient confidence in the healthcare system and increase healthcare costs. Hospitals must take a medication error prevention approach and also prepare various methods of managing medication errors once they have occurred. The necessity of a medication error reporting system should be emphasized. In Korea, with regard to medication errors, we have a long way to go. We have no documented data available on error rates, no published studies, and no error reporting system. In conclusion, medication errors are no longer a guarded, guilty-ridden professional secret in Korea. They should be considered problems in public healthcare policy. Therefore, we need to establish a medication error prevention and management system at the national level including a national error reporting system in the near future.

Prescription, Transcription and Administration Errors in Out-Patient Day Care Unit of a Regional Cancer Centre in South India

Mathaiyan, Jayanthi,Jain, Tanvi,Dubashi, Biswajit,Batmanabane, Gitanjali Asian Pacific Journal of Cancer Prevention 2016 Asian Pacific journal of cancer prevention Vol.17 No.5

Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

Factors affecting willingness to medical error-reporting of nursing students

Eunsim Kim,Juyoun Yu 한국간호과학회 2021 한국간호과학회 학술대회 Vol.2021 No.10

Aim(s): Anyone can make mistakes. Nurses should be able to report medical errors, and should be able to find the causes of errors and manage risks through the reporting. This study was conducted to identify factors affecting nursing students’ willingness to medical error-reporting. Method(s): A cross-sectional design was used and 175 senior nursing students participated the web-based questionnaire that included ‘attitude and knowledge towards medical errors reporting’, ‘ethical sensitivity’, ‘systems thinking’, and ‘willingness to medical error-reporting’. Data were analyzed using descriptive statistics, t-test, ANOVA, Pearson’s correlation coefficients and multiple linear regressions with SPSS/WIN 25.0 program. Result(s): Willingness to report adverse events and to report near miss were significantly correlated with attitude (r=.48, p<.001 and r=.31, p<.001), and knowledge (r=.18, p=.015 and r=.18, p=.021) on medical error-reporting, ethical sensitivity (r=.50, p<.001, and r=.30, p<.001), systems thinking (r=.49, p<.001, and r=.25, p<.001) respectively. Willingness to report adverse events and to report near miss had also a significant correlation (r=.59, p<.001). Factors significantly affecting willingness to report adverse events included systems thinking (β=.25, p=.002), medical errors reporting attitude (β=.23, p=.002), and ethical sensitivity (β=.21, p=.011), and these variables accounted for 34.3% (F=23.73, p<.001). Factors significantly affecting willingness to report near miss included medical errors reporting attitude (β=.17, p=.047) that accounted for 11.5% (F=6.68, p<.001). Conclusion(s): In order to increase nursing students’ willingness to medical error-reporting, integrated education is needed to improve attitude and knowledge on medical error-reporting, ethical sensitivity, and systems thinking.

의료 전문직 윤리교육과 합리적인 의료오류보고 체계 마련을 통한 의료분쟁의 예방 -일개 지역응급의료센터 의료오류보고 체계를 통한 민원 분석-

황순영 ( Soon Young Hwang ),배현아 ( Bae Hyun A ) 한국의료윤리학회 2008 한국의료윤리학회지 Vol.11 No.1

Purpose: Claims of malpractice and medical error are on the rise in South Korea. In this paper we argue that, in order to prevent or reduce such medical disputes, ethical education must be strengthened and an effective system for reporting medical errors must be established. Method: The research subjects for this study were patients who complained of inadequate treatment at the emergency center of one Korean hospital between January 2006 and December 2007. The complaints of these subjects were examined in order to determine the nature and cause of the complaints, including any human factors that led to the complaints. Result: A total 54 complaints were reported. Among these, "unkindness" was the most frequently reported complaint. In 27 (49%) of the cases, the cause of the complaint was traced to a human factor, with "lack of explanation" and "bad attitude" totally 69% of the cases. Such complaints were resolved by a variety of methods, including further explanations, apologies, reduction or exemption from the cost of treatment or asking for assistance from related departments. Conclusion: Patients that experience medical errors tend to lose trust in the doctor-patient relationship, which hinders the resolution of such medical errors. This study emphasizes the need to strengthen ethical education and establish a proper procedure for reporting medical errors in order to prevent and resolve medical error and the disputes to which they give rise.

연구논문 : 의료오류 공개에 대한 대학생들의 태도 조사

이수현 ( Su Hyun Lee ),김한아 ( Han A Kim ),한흥식 ( Heung Sik Han ),김성수 ( Sung Soo Kim ) 한국의료윤리학회 2011 한국의료윤리학회지 Vol.14 No.3

Object: The purpose of this study was to identify the attitudes of patients regarding medical error. Methods: The questionnaires were administrated to 145 college students in Busan, one hundred twenty three usable 123 questionnaires were analyzed. The questionnaires consist of 4 major concepts; 1) knowledge, 2) attitudes toward disclosure of medical error, 3) expectations for doctors` behaviors, 4) barriers to the disclosure of the medical error. Results: Approximately 92% of respondents supported the immediate disclosure of medical errors, and 62.6% supported full disclosure including near misses. Approximately 57% believed that it would be most effective if doctors themselves communicated errors to patients, while almost 93% said that it was a doctor`s obligation to do so. Regarding reasons for disclosure, 44.7% said that it would reduce doctors` feelings of guilt, while 45.5% said that it would also increase patient trust for doctors. Respondents also thought that the barriers to the full disclosure of medical errors were (1) damaged reputations (30.9%), (2) worries about medical lawsuits (22.8%), and (3) professional discipline (22.0%). Conclusion: Most of the participants in this survey support the immediate disclosure of medical errors regardless of the seriousness of the error. Furthermore the participants regarded disclosure of medical error as doctors` obligation. In order to meet the patients` high expectation regarding the medical error, this might be a good time for us to find a way to close the gap between patients` expectation and doctors` current practice.

병원급 의료기관에서의 투약오류 관련 요인

윤숙희 학습자중심교과교육학회 2022 학습자중심교과교육연구 Vol.22 No.17

Objectives This study aimed to identify factors related to medication errors in hospitals, provide basic data for medication safety, and to provide evidence to develop an intervention program to prevent medication errors. Methods This cross-sectional descriptive study was using the 2021 patient safety report data released by Korea Institute for Healthcare Accreditation. Of the total of 13,146 patient safety incidents, 4,198 medication errors were used, excluding psychiatric hospitals, oriental medicine hospital, and missing data were excluded. Descriptive statistics, Chi-square test, and multinominal logistic analysis were performed using SPSS 26.0 program. Results Factors affecting adverse events of medication errors were age, the place of occurrence and bed size. In addition, the factors influencing the sentinel event of medication error were the evening shift, the place of occurrence. Among the medication errors 70.4% (1,201) were near misses, 26.1%(445) were adverse events, and 3.5% (59) were sentinel events. Conclusions In order to prevent medication errors in medical institutions, factors that can affect medication errors by work department should be identified in various aspects, such as organizational, management, system, and human factors, and sufficient medical personnel, positive working environment, and medication safety system should be improved. 목적 본 연구는 병원급 의료기관에서의 투약오류 관련 요인을 파악하여 투약안전을 위한 기초자료를 제공하고 투약 오류 예방을위한 중재 프로그램 개발을 수행하기 위해 근거자료를 제시하기 위해 이차분석 자료를 활용한 후향적 조사연구이다. 방법 연구 목적에 따라 의료기관 인증평가원에서 공개한 2021년 환자안전보고데이터를 활용하여 환자안전사고 총 13,146건에서투약오류 4,198건 중 정신병원, 한방병원을 제외하였고 병원급 의료기관에서 결측치를 제외한 1,705건을 대상으로 SPSS/WIN 26.0 프로그램을 활용하여 기술통계, Chi-square test, 다항로지스틱 분석을 수행하였다. 결과 투약오류의 위해 정도는 근접오류는 70.4%(1,201명), 위해사건 26.1%(445명), 적신호사건 3.5%(59명)로 나타났다. 투약오류의 근접오류, 위해사건, 적신호 사건의 위해정도는 연령, 근무시간, 발생장소, 병원 유형, 병상 규모에 따라 차이가 있었고, 투약오류의 위해사건에 영향을 미치는 요인은 연령, 발생 장소, 병상 규모였으며, 투약 오류의 적신호 사건에 영향 미치는 요인은 초번근무, 발생 장소로 확인되었다. 결론 의료기관에서 투약 오류를 예방하기 위해서는 근무 부서별 투약오류에 영향을 미칠 수 있는 요인을 조직적, 관리적, 시스템, 인적 요인 등 다양한 측면으로 파악하고 충분한 의료인력 확보, 긍정적 근무환경 조성, 투약 안전시스템 개선과 더불어 투약오류 보고에 대한 환류와 개선 활동이 적극적으로 이루어져야 한다.

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

Ulas, Arife,Silay, Kamile,Akinci, Sema,Dede, Didem Sener,Akinci, Muhammed Bulent,Sendur, Mehmet Ali Nahit,Cubukcu, Erdem,Coskun, Hasan Senol,Degirmenci, Mustafa,Utkan, Gungor,Ozdemir, Nuriye,Isikdogan Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.5

Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

A study on the mechanism and countermeasures of medical devices incidents

( Haizhe Jin ),( Masahiko Munechika ),( Masataka Sano ),( Chisato Kajihara ),( Masaaki Kaneko ),( Fu Guo ) 한국품질경영학회 2015 한국품질경영학회 학술대회 Vol.2015 No.2

Purpose: This study will focus on the human, medical devices and human-computer interactions to analyze the medical devices incidents. Based on the analysis result, this study will suggest the mechanism of medical devices incidents and the countermeasure methods. Approach: In this study, we summarize the mechanism of medical devices incidents through the analysis and research on the cases of medical devices incidents. Mechanism of medical devices incidents will consider the error-process, error-factors and the operating environments. The consideration point is the human, medical devices and human-computer interactions. Based on the explored mechanism of medical incidents, this study will establish the countermeasures through eliminating the error-factors of medical devices incidents. Methods to establish the countermeasures will consider the characteristics of human, features of operating environment and medical devices. In order to ensure the countermeasure``s effect, the countermeasure ideal is by improving the features of operating environment and operating devices to cater human``s characteristics. Findings: Through this study we will present following two: (l) Propose the general mechanism which can summarize the incidents of medical devices, (2) Propose the countermeasures which based on the mechanism and can solve the practical problems. Value of paper: Three aspects of human, devices and the interaction caused the medical devices incidents. In the past research on the medical devices, one or two aspects are considered, but a few of research combine the three aspects. To consider the three aspects and propose the useful mechanism and countermeasure method is one of the value of this paper. Using the practical case to propose scientific result and to solve the practical medical problems is also the value of this paper.