• Quality Improvement in Health Care
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• v.18 no.1
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• pp.79-87
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• 2012

문제: 투약오류는 의료기관 전반에서 가장 많이 발생하는 오류의 하나이며, 환자에게 중대한 위해를 초래하기도 한다. 특히 고농축전해질은 문제발생의 가능성과 위험성이 높아 지속적인 관리 및 교육을 필요로 하고 있다. 목적: 발생한 투약오류 건에 대한 근본원인분석을 시행함으로써 유사사례가 발생하는 것을 예방하여 환자안전을 도모하고자 한다. 의료기관: 연세대학교 세브란스병원 질 향상 활동: 투약오류 건에 대해 근본원인분석 시행 후 고위험약물 관련 내규를 보완하였고, 고위험약물에 대한 Alert System 개발, 고위험약물 라벨 부착, 약 처방 관련 의료진 교육을 시행하였다. 개선효과: 고위험약물 투여와 관련된 시스템 개선 활동 이후 유사사례는 발생하지 않았고, 의료진 교육을 통하여 환자안전에 대한 인식과 중요성을 더욱 증가시켰다.

• The Journal of the Convergence on Culture Technology
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• v.10 no.3
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• pp.625-633
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• 2024

This study was attempted to identify the perception and experience of hospital nurses on medication errors of high-risk intravenous drugs, and to identify the causes of medication errors and ways to improve them. The subjects of the study were nurses with work experience related to high-risk intravenous administration working at a university hospital located in D City, and data were collected between May 16 ~ 30, 2021. As a result of the study, six key factors were identified as the key factors in the safety of high-risk intravenous injections: the lack of a protocol for the administration of major drugs in each ward, the lack of training in the operation of the injection machine, the lack of standardized procedures for administering high-risk intravenous injections, the lack of individualized medication training for nurses, the lack or lack of the hospital's own drug list, and the lack of identification of drugs packaged in similar containers. At the nursing practice level, it is proposed to apply a high-risk intravenous medication safety program and conduct a future study to identify safety outcome indicators.

• The Journal of the Korea Contents Association
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• v.20 no.10
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• pp.424-435
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• 2020

The study was descriptive survey research for establishment of patient safety culture in small and medium-sized hospitals as providing baseline data of educational program regarding safe medication and prevention of near miss on medication, checking influencing factors of nurses near miss experience on medication in small and medium-sized hospital. The collected data was analyzed by SPSS/WIN 20.0 program to obtain mean, frequency, x²-test, independent t-test, one-way ANOVA, logistic regression. The influencing factors of near miss experience on medication was working department and patient safety culture among general characteristic. The nurses who were working in general ward had lesser chance to experience near miss rather than nurses working in special department (Odds ratio:2.23, 95%, Confidence Interval: 1.07~4.67, p=.032). The 1 point higher in patient safety culture, the lesser chance to experience in near miss (Odds ratio: 2.24, 95% Confidence Interval: 1.02~4.95, p=.045). To sum up the result of this study, nurses working in special department had higher chance to experience near miss rather than nurses working in general wards. The higher patient safety culture awareness was the lower near miss was experienced. Thus, miss surveillance system for improvement of nurses' patient safety culture awareness should be developed. Moreover, educational program for medication considering nurses' career and department' character should be requested with simulation training considering and theory education.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.15 no.2
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• pp.979-988
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• 2014

Purpose: The purpose of this study was to examine the relationship between nurse's perception of organizational characteristics including safety climate and work environment and barrier to medication error reporting. Methods: We surveyed 334 nurses from 7 hospitals. An assessment survey was consisted of modified safety climate scale, practice environment scale and barrier to medication error reporting. The data were collected from September 2012. Descriptive statistics, Pearson correlation coefficient, canonical correlation were used. Results: Organizational characteristics were related to barrier to medication error reporting with three significant canonical variables. The first canonical correlation coefficient was .50(Wilks' ${\lambda}$=0.61, df=32, p<.001), that of the second was .35(Wilks' ${\lambda}$=0.81, df=21, p<.001) and that of the third was .22(Wilks' ${\lambda}$=0.93, df=12, p=.018). The first variate indicated higher perception of safety climate variables and work environment variables were related lower barrier to medication error reporting variables except fear for error reporting. The second variate showed higher perception of 'safety climate between healthcare provider' and higher 'nurse participation in hospital affairs' and 'staffing and resource adequacy' were related to lower 'fear' and 'administrative response' in barrier to medication error reporting variables. Conclusion: Strategies for barrier to medication error reporting and improvement of organizational characteristics including safety climate and work environment should be implemented.

• Korean Journal of Adult Nursing
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• v.27 no.6
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• pp.673-683
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• 2015

Purpose: This study was aimed to identify the mediating and moderating effects of safety-specific transformational leadership on the relationship between barrier to and intention of reporting medication errors. Methods: Two hundred thirty seven nurses from seven different hospitals participated in the study. Safety-specific transformational leadership was measured by an instrument with 10 items, barrier to reporting medication errors with 16 items, and intention of reporting medication errors with 3 items. The data was collected from September to October 2012. Descriptive statistics, factor analysis, t-test, ANOVA, Pearson correlation coefficient and a hierarchial regression analysis were used. Results: There were significant negative correlations between the subcategories of barrier to reporting medication errors and intention of reporting medication errors (r=-.16~-.27, p<.001), and a positive correlation between the intention and safety-specific transformational leadership (r=.25, p<001). Transformational leadership was a mediator between barrier to and intention of reporting medication errors. Conclusion: Safety-specific transformational leadership mediated the relationships between barrier to and intention of reporting medication errors. Enhancing safety-specific transformational leadership of nursing unit managers is necessary to increase the intention to reporting medication errors.

• Journal of Korean Academy of Nursing
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• v.42 no.4
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• pp.568-578
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• 2012

Purpose: The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. Methods: The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Results: Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. Conclusion: The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

• Journal of Korean Critical Care Nursing
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• v.8 no.1
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• pp.1-10
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• 2015

This study was conducted to examine the relationship among the error risk of high-alert medication, attitudes to single-person checking of medication, and medication safety activities. The participants were 60 nurses working in the intensive care unit. Data were analyzed using descriptive analysis, t-test, analysis of variance, and Pearson's correlation coefficient. The mean scores of the knowledge and certainty of high-alert medication were $0.71{\pm}0.11$ and $2.74{\pm}0.59$, respectively. The mean score of the error risk of high-alert medication was $1.63{\pm}0.24$ and that of attitudes to single checking medication was $3.32{\pm}0.49$. The error risk of high-alert medication had a positive correlation with nurses' attitudes to single checking medication (r = .258, p = .047), which is correlated with the scores for certainty of knowledge (r = .284, p = .028). Based on the results of this study, continuing education for high-alert medication and the development of an accurate protocol for single checking medication are needed to improve the stability of high-alert medication.

• Journal of Korean Academy of Nursing Administration
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• v.19 no.1
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• pp.28-38
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• 2013

Purpose: Human factor is one of the major causes of medication errors. The purpose of this study was to identify nurses' perception and experience of medication errors, examine the relationship of Dominance, Influence, Steadiness, Conscientiousness (DISC) behavior patterns and medication errors by nurses. Methods: A descriptive survey design with a convenience sampling was used. Data collection was done using self-report questionnaires answered by 308 nurses from one university hospital and two general hospitals. Results: The most frequent DISC behavioral style of nurses was influence style (41.9%), followed by steadiness style (23.7%), conscientiousness style (20.4%), and dominance style (14.0%). Differences in the perception and experience level of medication errors by nurses' behavioral pattern were not statistically significant. However, nurses with conscientiousness style had the lowest scores for in experience of medication errors and the highest scores for perception of medication errors. Conclusion: The results of this study show that identification of the behavior pattern of nurses and application of this education program can prevent medication errors by nurses in hospitals.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.21 no.4
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• pp.403-412
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• 2014

Purpose: Shift work disrupts the synchronization between the human biological clock and the environment. Sleep disturbances are common for shift work nurses, and may threaten patient safety. This study was done to investigate the sleep characteristics and medication errors (ME) of intensive care unit (ICU) nurses who work shifts, and ascertain if there is an association between these factors. Methods: Data were collected using a self-report questionnaire from 126 ICU nurses on three shifts. Collected data included their sleep characteristics including sleep patterns and sleep disturbances, and ME for the past 2 weeks. Results: There were significant differences in sleep duration and sleep latency according to shift. Day shift nurses had the shortest sleep duration, and their sleep latency was the longest (about 49 minutes) compared to nurses on evening and night shifts; 54% reported sleep disturbances, 16% experienced ME, and among these nurses 50% were on the night shift. Logistic regression analysis revealed significant associations between nurses' sleep duration and ME (adjusted OR 0.52 [95% CI 0.32-0.85]). Conclusions: The results confirmed that shift work nurses in the ICUs experience sleep disturbance, and that less sleep is associated with ME.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.14 no.1
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• pp.6-17
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• 2007

Purpose: This study was carried out to investigate perception and experience of medication errors by nurses. Method: Data collection through a survey was performed using structured questionnaires over the period of September 1 to October 15, 2004. Questionnaire were delivered to 222 nurses from 15 hospitals; thereafter, 205 questionnaires were responded (i.e., 92% response rate). The subject in the study was a nurse who had been working in the hospital for less than one year. Results: The average perception rate was 87.5%. The perception rates of subjects in medication errors from four areas are 62% in wrong dosage form for drug administration, 61.5% in air into an IV set, 63% in crystals in an IV lines, and 83.5% in wrong time. The experience rates of subjects in medication errors from four areas are 85.5% in wrong time, 39.5% in wrong injection site, 34.5% in omission error, and 28% in wrong patient. Conclusion: The average perception rate and experience rates of medication errors were 87.5% and 23.5%, respectively. Education about the Five right in medication and knowledges about drugs would improve the perception of medication errors of nurses whose work experience is less than one year, and prevent them from medication errors.