한국의료질향상학회지 (Quality Improvement in Health Care)

  • 제29권2호
  • /
  • Pages.15-31
  • /
  • 2023
  • /
  • 1225-7613(pISSN)
  • /
  • 2288-078X(eISSN)
한국의료질향상학회 (Korean Society for Quality in Health Care)
권호 표지
DOI QR코드

DOI QR Code

간호 관련 환자안전사건의 특성과 질적 내용 분석: 의료 소송 판결문(2014~2018년)을 이용한 이차자료 분석

Characteristics of Nursing-related Patient Safety Incidents and Qualitative Content Analysis: Secondary data Analysis of Medical Litigation Judgment (2014~2018)

  • 김민지 (연세대학교 대학원 의료법.윤리학협동과정) ;
  • 이원 (중앙대학교 간호학과) ;
  • 김상희 (연세대학교 간호대학) ;
  • 김소윤 (연세대학교 의과대학 인문사회의학교실 의료법윤리학과)
  • Min-Ji Kim (Department of Medical Law and Ethics, Graduate School, Yonsei University) ;
  • Won Lee (Department of Nursing, Chung-Ang University) ;
  • Sang-Hee Kim (College of Nursing, Yonsei University) ;
  • So-Yoon Kim (Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, College of Medicine, Yonsei University)
  • 투고 : 2023.05.28
  • 심사 : 2023.10.04
  • 발행 : 2023.12.31
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

Purpose: This study aimed to identify the characteristics of patient safety incidents (PSIs) related to nursing and to provide primary data for preventing the recurrence of similar incidents. Methods: This secondary analysis study included damage claims rulings filed for clinical negligence from 2014 to 2018 that contained the keyword 'nurse'. It excluded judgments irrelevant to nursing care and in which clinical negligence or causal damages were overruled. A total of 93 cases were analyzed. The characteristics of PSIs were derived through descriptive statistics, and two instances of nursing-related PSIs were examined by qualitative content analysis focusing on root causes. Results: The analysis of PSIs related to nursing suggested that the medical institutions where the PSIs occurred most frequently were hospitals, and the most common types of PSIs were medication, surgery, and treatment/procedure, in that order. In addition, it indicated that nursing-related PSIs occurred most frequently in general wards during the day shift, with the most common related nursing practice being managing potential risk factors. The qualitative analysis showed that careless monitoring and institutional inertia were causes of PSIs. Conclusion: To prevent nursing-related PSIs, nurses need to individually monitor and assess patient conditions. In addition, support should be accompanied by the improvement in the systems in place aimed at preventing the recurrence of nursing-related PSIs at the institutional and national level, such as securing appropriate nursing personnel and improving labor conditions.

키워드

과제정보

This study was supported by the Hanmaeum scholarship of the Seoul Nurses Association.

참고문헌

  1. World Health Organization. Conceptual framework for the international classification for patient safety. Geneva, Switzerland: World Health Organization; 2010.
  2. World Health Organization. Patient safety incident reporting and learning systems: technical report and guidance. Geneva, Switzerland: World Health Organization; 2020.
  3. Korean Patient Safety Reporting & Learning System. 2022 patient safety statistics yearbook. Seoul, Korea: Korean Institute for Healthcare Accreditation; 2023.
  4. The Supreme Court of Korea. Judicial yearbook. Seoul, Korea: National Court Administration; 2022.
  5. Korea Medical Dispute Mediation and Arbitration Agency. 2022 medical dispute mediation and arbitration yearbook. Seoul, Korea: Korea Medical Dispute Mediation and Arbitration Agency; 2023.
  6. Korea Consumer Agency. 2021 yearbook and casebook of consumer damage relief. Eumseong, Korea: Korea Consumer Agency; 2022.
  7. Mira JJ, Lorenzo S, Carrillo I, Ferrus L, Perez-Perez P, Iglesias F, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims. BMC Health Services Research. 2015;15(1):1-9. https://doi.org/10.1186/s12913-015-0994-x
  8. Anderson JE, Kodate N. Learning from patient safety incidents in incident review meetings: organisational factors and indicators of analytic process effectiveness. Safety Science. 2015;80:105-14. https://doi.org/10.1016/j.ssci.2015.07.012
  9. Panesar S, Carson-Stevens A, Salvilla S, Sheikh A. Patient safety and healthcare improvement at a glance. New Jersey, USA: John Wiley & Sons; 2014.
  10. Wachter R. Understanding patient safety. 2nd ed. New York, USA: McGraw-Hill Medical; 2012.
  11. Ministry of Health and Welfare. 2022 health and welfare statistical yearbook. Sejong, Korea: Ministry of Health and Welfare; 2022.
  12. Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety. Keeping patients safe: transforming the work environment of nurses. Washington (DC), USA: National Academies Press (USA); 2004.
  13. Persaud S. Diversifying nursing leadership through commitment, connection, and collaboration. Nursing Administration Quarterly. 2020;44(3):244-50. https://doi.org/10.1097/NAQ.0000000000000422
  14. Kim KK, Cheon H-S, Kim NH. Nursing case law and standard of care. Paju, Korea: Soomoonsa; 2022.
  15. Hur HK, Kim KK, Jung JS. A systematic content analysis of the closed nursing malpractice claims related to patients' safety. Journal of Korean Academy of Nursing Administration. 2023;29(2):99-108. https://doi.org/10.11111/jkana.2023.29.2.99
  16. Kim YS, Kim TE. Analysis of legal liability in medical accident due to nursing practice through precedents. Korean Journal of Legal Medicine. 2019;43:119-28. https://doi.org/10.7580/kjlm.2019.43.4.119
  17. Park IS, Kang S-Y, Kim K-S, Park HS, Suh Y-O, Ahn SY. Analysis of registered nurses' job, learning objectives and the association between them. Seoul, Korea: Korea Health Personnel Licensing Examination Institute; 2015.
  18. Liu Y, Zhao G, Li F, Huang X, Hu D, Xu J, et al. Nursing-related patient safety events in hospitals. Journal of Huazhong University of Science and Technology. 2009;29(2):265-8. https://doi.org/10.1007/s11596-009-0227-9
  19. Supreme Court of Korea. What is the judgment search and reading system? [Internet]. [cited 2023 Aug 13]. Available from: https://www.scourt.go.kr/portal/information/trialeodes/overview/index.html.
  20. Lincoln YS, Guba EG. Naturalistic inquiry. California, USA: SAGE Publications; 1985.
  21. Kim MJ, Shin SH, Park JY. Medicolegal implications from litigations involving necrotizing fasciitis. Annals of Surgical Treatment and Research. 2020;99(3):131-7. https://doi.org/10.4174/astr.2020.99.3.131
  22. Shin SH, Kim SY, Jang SG, Lee W. Analysis of closed medical litigation in urology. Investigative and Clinical Urology. 2017;58(5):317-23. https://doi.org/10.4111/icu.2017.58.5.317
  23. Kim MJ, Jang SG, Kim IS, Lee W. A study on the status and contributory factors of adverse events due to negligence in nursing care. Journal of Patient Safety. 2021;17(8):e904-e10. https://doi.org/10.1097/PTS.0000000000000791
  24. Lee MA, Cho HJ, Ahn SH, Kim HJ. Perceptions on fixed night shift system and turnover intention of general hospital nurses. Journal of Korean Academy of Nursing Administration. 2015;21(5):519-29. https://doi.org/10.11111/jkana.2015.21.5.519
  25. Joint Commission on Accreditation of Healthcare Organizations. Root cause analysis in health care: tools and techniques. Illinois, USA: Joint Commission on Accreditation of Healthcare Organizations; 2000.
  26. Choi E-Y, Lee H-J, Ock M-S, Lee S-I. Development of Korean root cause analysis software for analyzing patient safety incidents. Quality Improvement in Health Care. 2018;24(1):9-22. https://doi.org/10.14371/QIH.2018.24.1.9
  27. Lee W, Kim SY, Lee MJ. Application of malpractice cause analysis tools for preventing repeat medical accident. Korean Journal of Medicine and Law. 2014;22(1):21-42. https://doi.org/10.17215/kaml.2014.06.22.1.21
  28. Rooney JJ, Heuvel LNV. Root cause analysis for beginners. Quality Progress. 2004;37(7):45-56.
  29. Ministry of Health and Welfare, Korea Institute for Healthcare Accreditation. 4th cycle acute hospital accreditation criteria and standard guidelines. Seoul, Korea: Korea Institute for Healthcare Accreditation; 2021.
  30. Koo MJ. Analysis of medication errors of nurses by patient safety accident reports. Journal of Korean Clinical Nursing Research. 2021;27(1):109-19.
  31. Dill MCP, Arboit EL, Kaefer CT, Arboit J. Perceptions about an instrument used for patients' evaluation and discharge from post-anesthesia care units. Revista de Pesquisa Cuidado e Fundamental Online. 2018;10(3):711-9. https://doi.org/10.9789/2175-5361.2018.v10i3.711-719
  32. Kremer MJ, Hirsch M, Geisz-Everson M, Wilbanks BA, Clayton BA, Boust RR, et al. Preventable closed claims in the AANA foundation closed malpractice claims database. AANA journal. 2019;87(6):468-76.
  33. Yamamoto-Takiguchi N, Naruse T, Fujisaki-Sueda-Sakai M, Yamamoto-Mitani N. Characteristics of patient safety incident occurrences reported by japanese homecare nurses: a prospective observational study. Nursing Reports. 2021;11(4):997-1005. https://doi.org/10.3390/nursrep11040090
  34. Ock M, Lee S-I. Disclosure of patient safety incidents: implications from ethical and quality of care perspectives. Journal of the Korean Medical Association. 2017;60(5):417-27. https://doi.org/10.5124/jkma.2017.60.5.417
  35. Ock M, Lim SY, Jo MW, Lee SI. Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review. Journal of Preventive Medicine and Public Health. 2017;50(2):68-82. https://doi.org/10.3961/jpmph.16.105
  36. TJ T-B, WJ U-P. Nursing admission assessment and examination. Florida, USA: StatPearls Publishing; 2023.
  37. Eun Y, Jeon MY, Gu MO, Cho YA, Kim JY, Kwon JS, et al. Utilization of evidence-based clinical nursing practice guidelines in tertiary hospitals and general hospitals. Journal of Korean Clinical Nursing Research. 2021;27(3):233-244.
  38. Cho S-H, Seong J, Jung YS, You SJ, Sim WH. Recommendation for the amendment of inpatient nursing fee schedules based on nurse staffing standards in general wards of tertiary hospitals and general hospitals. Journal of Korean Clinical Nursing Research. 2022;28(2):122-36.
  39. Park JO, Kim HY, Roh GS, Roh YD, Park MB, So JE, et al. Comparison of nursing activity time according to the change in grade of nursing management fee in one university hospital. Journal of Korean Clinical Nursing Research. 2010;16(1):95-105.
  40. Hong KJ, Cho S-H. Changes in nurse staffing grades in general wards and adult and neonatal intensive care units. Journal of Korean Clinical Nursing Research. 2017;23(1):64-72.
  41. Korea Health Personnel Licensing Examination Institute. National examination passing rate by year [Internet]. [cited 2022 Nov 12]. Available from: https://www.kuksiwon.or.kr/peryearPass/list.do?seq=13&srchWord=05.ation.
  42. Lee T, Kang KH, Ko YK, Cho S-H, Kim E-Y. Issues and challenges of nurse workforce policy: a critical review and implication. Journal of Korean Academy of Nursing Administration. 2014;20(1):106-16. https://doi.org/10.11111/jkana.2014.20.1.106
  43. Cho S-H, Lee J-Y, June K-J, Hong KJ, Kim Y. Nurse staffing levels and proportion of hospitals and clinics meeting the legal standard for nurse staffing for 1996~2013. Journal of Korean Academy of Nursing Administration. 2016;22(3):209-19. https://doi.org/10.11111/jkana.2016.22.3.209
  44. Ahn SI, Lee W, Song DH. A descriptive study on the civil lawsuits of medical malpractice occurred during psychiatric ward treatment. Psychiatry Investigation. 2020;17(9):865.
  45. Hyeon CW, Lee JY, Jang S, Cho SI, Kim S, Lee W, et al. Medical malpractice related to drug-induced anaphylaxis: an analysis of lawsuit judgments in South Korea. Medicine (Baltimore). 2019;98(23):e15996.
  46. Jung JY, Kim SY, Kim DG, Kim CB, Chi K-C, Kang WK, et al. Analysis of lawsuit cases in the department of surgery in Korea. Annals of Surgical Treatment and Research. 2018;94(3):113-7. https://doi.org/10.4174/astr.2018.94.3.113
  47. Shin S, Jang SG, Min K, Lee W, Kim SY. The legal doctrine on the liability of physicians in medical malpractice lawsuits involving complex regional pain syndrome. Journal of Korean Medical Science. 2018;33(9):e46.
  48. Palojoki S, Makela M, Lehtonen L, Saranto K. An analysis of electronic health record-related patient safety incidents. Health Informatics Journal. 2017;23(2):134-45. https://doi.org/10.1177/1460458216631072
  49. Baylis D, Price J, Bowie P. Content analysis of 50 clinical negligence claims involving test results management systems in general practice. BMJ Open Quality. 2018;7(4):e000463.