• Title/Summary/Keyword: Hospital incident reporting

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A Study on Patient Safety Culture, Incident Reporting and Safety Care Activities of Clinical Nurses in a University-Affiliated Hospital (병원 간호사의 환자안전문화 인식, 사건보고 및 안전간호활동: 일 대학병원을 중심으로)

  • Ha, Sujin;Lee, Minju
    • Journal of muscle and joint health
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    • v.26 no.1
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    • pp.35-45
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    • 2019
  • Purpose: This study aimed to investigate perception of patient safety culture, incident reporting, and safety care activities among clinical nurses and to identify factors associated with the safety care activities. Methods: Structured questionnaires were used to collect data from 155 nurses who were involved in direct patient-care. Results: Descriptive statistical anaylses revealed that the mean score of patient safety culture was $3.26{\pm}0.32$ and $4.19{\pm}0.41$ was for the safety care activities. In incident reporting, reporting intention ($3.56{\pm}0.68$), belief in improvement ($3.42{\pm}0.60$), worry about appraisal ($3.37{\pm}0.65$) and reporting knowledge ($3.36{\pm}0.72$) respectively. Correlational analyses showed that perceived patient safety culture (r=.36), reporting intention (r=.34), belief in improvement (r=.32), and the knowledge (r=.38) in incident reporting were positively correlated with safety care activities, while the worry about appraisal in incident reporting attitude was negatively correlated. The factors associated with safety care activities were incident reporting knowledge (${\beta}=.31$, p<.001), supervisor/managers' attitudes toward patient safety culture (${\beta}=.29$, p<.001), belief in improvement of incident reporting attitude (${\beta}=.16$, p=.041). Conclusion: These results suggest that to improve safety care activities among hospital nurses, it is necessary to educate nurses on incident reporting. Also, a system-level approach is needed to support leadership in patient safety and to provide positive feedback on incident reporting.

A Convergence Study of Nurses' Incident Reporting and Perceived Safety Climate (간호사의 사건보고와 안전분위기 인지에 대한 융합연구)

  • Koh, Yu-Mi;Kim, Ju-Sung
    • Journal of the Korea Convergence Society
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    • v.9 no.4
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    • pp.443-452
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    • 2018
  • The purpose of this study was to identify the factors affecting perceived safety climate and the level of incident reporting attitude, incident reporting knowledge and safety climate. The data were collected by structured questionnaires from 240 nurses and were analyzed with descriptive statistics, t-test, ANOVA, Scheffe test, Pearson's correlation coefficients and multiple regression. The level of incident reporting attitude and incident reporting knowledge was 3.34 and 3.05. The level of safety climate was 3.25. Incident reporting knowledge and safety climate have a significant positive association with incident reporting attitude(r=.33, p<.001; r=.38, p<.001). Incident reporting knowledge was positively associated with safety climate(r=.32, p<.001). Factors influencing safety climate were incident reporting knowledge, belief in improvement and reporting intention which explained 24.7% of the variance(F=12.22, p<.001). The findings indicate that to improve incident reporting knowledge with positive attitude and safety climate should be considered as patient safety strategy and should endeavour to develop interventions for safety.

Study on Factors Affecting Nurses' Experience of Non-Reporting Incidents (병원 간호사의 사건보고 불이행 경험여부에 영향을 미치는 요인)

  • Kim, Ki-Kyong;Song, Mal-Soon;Rhee, Kae-Sook;Hur, Hea-Kung
    • Journal of Korean Academy of Nursing Administration
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    • v.12 no.3
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    • pp.454-463
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    • 2006
  • Purpose: This study was designed to identify the factors affecting the nurses' experience of non-reporting adverse incidents in hospital. Methods: This study is a cross-sectional, descriptive survey design and nonrandom, convenience sampling. Study subjects were 392 clinical nurses, who have agreed to be the subject of this research. The measuring instrument of attitudes toward incident reporting was developed by the authors. The questionnaire which consisted of 17 items about worry about appraisal, the belief in improvement, the intention of reporting, and knowledge was measured by 5-point Likert-type scale. The estimate of internal consistency was alpha =.84. Analysis of data was done with use of mean, t-test, ANOVA, logistic regression with SPSS program. Results: Clinical nurses had experience of reporting incident (51.3%), non-reporting incident (76.5%). Statistically, significant differences were found between experiences group and non experience group in intention on reporting, belief on improvement, and worry about appraisal. Logistic regression analysis showed that the significant predictors were caused by report no-fault cases, belief on improvement, worry about appraisal. Conclusion: The result also indicated that, to improve the incident reporting and risk management, it might be necessary to give a belief that it results on improvement and remove concern about punishment through construction of no-blame system.

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Survey of Under-Reporting Rate and Related Factors after Blood and Body Fluid Exposure among Hospital Employees (병원직원의 환자 혈액 및 체액 노출 후 미보고 및 관련 요인)

  • Kim, Og-Son;Choi, Jeong-Sil;Jeong, Jae-Sim;Park, Eun-Suk;Yoon, Sung-Won;Jung, Sun-Young;Jin, Hye-Young;Kim, Kyeong-Mi
    • Korean Journal of Adult Nursing
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    • v.22 no.5
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    • pp.466-476
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    • 2010
  • Purpose: The purpose of this study was to examine the under-reporting rate and related factors after blood and body fluid (BBF) exposure among hospital employees. Methods: Fifteen hundred l employees were conveniently sampled from ten university and acute care hospitals. The survey questionnaire consisted of 37 items. Data were collected from September 10 to November 30, 2008. Results: The survey response rate was 88.7%. The 47.9% (638/1,331) of hospital employees were exposed to BBF and the mean number of exposure was $4.7{\pm}5.942$ within the previous year. Under-reporting rate after BBF exposure was 69.4% (443/638). By multi-variate logistic regression analysis, the exposure number, exposure type, infectious disease and hospital were independently related to the under-reporting of BBF among hospital employees. Conclusion: The under-reporting rate after being exposed to blood and body fluids was relatively high. To address this problem, educational programs are needed to decrease the under-reporting rate for healthcare workers. Further, it might be helpful if other factors related to under-reporting be investigated in future studies.

Trends in infection-related patient safety incident reporting before and during the COVID-19 pandemic in Korea (COVID-19 대유행 시기 전후 국내 감염관련 환자안전 사고 보고 현황 분석)

  • Eun-Jin Kim;Yeon-Hwan Park
    • Journal of Korean Biological Nursing Science
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    • v.25 no.2
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    • pp.95-104
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    • 2023
  • Purpose: The purpose of this study was to analyze the trends and characteristics of infection-related patient safety incident reporting before and during the coronavirus disease 2019 (COVID-19) pandemic in Korea, and to provide basic data for preventing infection-related patient safety incidents and improving their management. Methods: A cross-sectional analysis of secondary national data (Patient Safety Reporting Data) was conducted. In total, 517 infection-related patient safety incidents reported from 2018 to 2021 were analyzed. Changes in the number of reports before and during the COVID-19 pandemic and differences in variables related to infection-related patient safety incidents were analyzed using the chi-square test and independent t-test in SPSS 29.0. Results: This study found that infection-related patient safety incidents decreased during the COVID-19 pandemic compared to before the pandemic. Furthermore, incident-related characteristics, such as the type of healthcare organization, severity of harm, and post-incident actions, changed during the COVID-19 pandemic. Conclusion: The many changes in the infection control system and practices during the COVID-19 pandemic may have contributed to a decrease in the reporting of infection-related patient safety incidents. It is hoped that longitudinal studies on patient safety incidents related to the pandemic and analytical studies on factors influencing patient safety incidents will continue to be conducted to prevent and improve patient safety incidents.

Mediating Effects of Perceptions Regarding the Importance of Patient Safety Management on the Relationship between Incident Reporting Attitudes and Patient Safety Care Activities for Nurses in Small- and Medium-sized General Hospitals (중소병원 간호사의 사건보고태도와 환자안전간호활동의 관계에서 환자안전관리 중요성 인식의 매개효과)

  • Park, Young Mi;Nam, Keum Hee;Kang, Ki Noh;Nam, Jeong Ja;Yun, Yeon Ok
    • Journal of Korean Critical Care Nursing
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    • v.12 no.2
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    • pp.85-96
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    • 2019
  • Purpose : The purpose of this study was to examine the mediating effect of perceptions regarding the importance of patient safety management in the relationship between incident reporting attitudes and patient safety care activities for nurses in small-and medium-sized general hospitals. The objective was to provide a basis for planning tailored training programs aimed at improving patient safety care activities. Methods : This study was conducted with 187 participants in small- and medium-sized general hospitals in K city in South Korea from March 15 to March 31, 2019. The data collected from participants were analyzed using descriptive statistics, a t-test, ANOVA, Pearson's correlation coefficients, and a multiple regression using IBM SPSS/WIN 21.0 software. Results : Patient safety care activities were found to be correlated with incident reporting attitudes (r=.27, p < .001) and perceptions of the importance of patient safety management (r=.59, p < .001). Further, perceptions of the importance of patient safety management had a complete mediating effect (${\beta}=.409$, p < .001) on the relationship between incident reporting attitudes and patient safety care activities. Conclusion : Based on the findings of this study, tailored training programs regarding patient safety care activities focused on boosting perceptions of the importance of patient safety management are highly recommended to improve nurses' patient safety care activities in small- and medium-sized general hospitals.

A Study of Institutional Status of Risk Management for Radiotherapy in Foreign Country

  • Lee, Soon Sung;Shin, Dong Oh;Ji, Young Hoon;Kim, Dong Wook;An, Sohyoun;Park, Dong-Wook;Cho, Gyu Suk;Kim, Kum-Bae;Koo, Jihye;Oh, Yoon-Jin;Choi, Sang Hyoun
    • Progress in Medical Physics
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    • v.27 no.3
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    • pp.139-145
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    • 2016
  • With the development in field of industry and medicine, new machines and techniques are being launched. Moreover, the complexity of the techniques is associated to an increasing risk of incident. Especially, a small error in radiotherapy can lead to a serious patient-related incident, risk management is necessary in radiotherapy in order to reduce the risk of incident. However, in field of radiotherapy, there are no legally binding clauses for risk management and there is an absence of risk management systems at an institutional level. Therefore, we analyzed institutional status of risk management, reporting & classification systems, and risk assessment & analysis in 31 countries. For risk management and reporting systems, 65% of countries investigated had legislation or regulations; however, only 35% of countries used classification systems. It was found that 43% more countries had legislation for risk management in healthcare than those for radiotherapy; 19% more countries had reporting systems for healthcare than those for radiotherapy. For classification systems, 60% more countries had legislation, recommendation, and guidelines in the field of radiotherapy than those for healthcare. Recently, international institutes have published several reports for risk management and patient safety in radiotherapy, owing to which, countries adopting risk management for radiotherapy will gradually increase. Before adopting risk management in Korea, we should precisely understand the procedures and functions of risk management, in order to increase efficiency of risk management because classification & reporting system and risk assessment & analysis are connected organically, and institutional management is needed for high quality of risk management in Korea.

Analyzing Health Information Technology and Electronic Medical Record System-Related Patient Safety Incidents Using Data from the Korea Patient Safety Reporting and Learning System (환자안전보고학습시스템 자료를 활용한 의료정보기술 및 전자의무기록시스템 관련 환자안전사건 분석)

  • Cho, Dan Bi;Lee, Yu-Ra;Lee, Won;Lee, Eu Sun;Lee, Jae-Ho
    • Quality Improvement in Health Care
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    • v.27 no.2
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    • pp.57-72
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    • 2021
  • Purpose: At present, there are a variety of serious patient safety incidents related to problems in health information technology (HIT), specifically involving electronic medical records (EMRs). This emphasizes the need for an enhanced electronic medical record system (EMRS). As such, this study analyzed both the nature of and potential to prevent incidents associated with HIT/EMRS based on data from the Korea Patient Safety Reporting and Learning System (KOPS). Methods: This study analyzed patient safety incidents submitted to KOPS between August 2016 and December 2019. HIT keywords were used to extract HIT/EMRS incidents. Each case was reviewed to confirm whether the contributing factors were related to HIT/EMRS (HIT/EMRS-related incidents) and if the incident could have been prevented (HIT/EMRS-preventable incidents). The selected reports were summarized for general clarity (e.g., incident type, and degree of harm). Results: Of the 25,515 obtained reports, 2,664 incidents (10.4%) were HIT-related, while 2,525 (9.9%) were EMRS-related. HIT/EMRS-related incidents were the third largest type of incident followed by 'fall' and 'medication incidents.' More than 80% of HIT/EMRS-related incidents were medication-related, accounting for approximately one-third of the total number of medication incidents. Approximately 10% of HIT/EMRS-related incidents resulted in patient harm, with more than 94% of these deemed as preventable; further, sentinel events were wholly preventable. Conclusion: This study provides basic data for improving EMR use/safety standards based on real-world patient safety incidents. Such improvements entail the establishment of long-term plans, research, and incident analysis, thus ensuring a safe healthcare environment for patients and healthcare providers.

A Legal Framework for Improving Patient Safety in Korea (환자안전 관련 법의 구조와 현황)

  • Ock, Minsu;Kim, Jang Han;Lee, Sang-il
    • Health Policy and Management
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    • v.25 no.3
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    • pp.174-184
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    • 2015
  • This paper reviewed structure and current status of laws related to patient safety using patient safety law matrix to promote systematic approach in legal system of patient safety. Laws related to patient safety can be divided into three areas: laws for preventing; laws for knowing about; and laws for responding. In the case of Korea, gaps are especially prominent in the areas of laws for knowing about and responding. Patient safety law which will be enacted in July 2016 will fill the gap in the area of laws for knowing about. This law will be comprehensive law, covering the full spectrum of laws related to patient safety. However, after reviewing current patient safety law in Korea, the following drawbacks were identified: absence of code for grasping the current patient safety level; absence of code for mandatory reporting in patient safety reporting system; and absence of code for privilege about patient safety work product. Furthermore we need wider discussions about covering issues of open disclosure, apology law, coroners system, and complaint management system in patient safety law.

Development of Website-based Patient Safety Culture Promotion Program (Website를 이용한 환자안전문화 증진 프로그램의 개발)

  • Kim, Kyoung Ja
    • Journal of Korean Clinical Nursing Research
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    • v.19 no.1
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    • pp.152-167
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    • 2013
  • Purpose: The purpose of this study was to develop a website-based patient safety culture promotion program that could be implemented by nurses in real work scenarios. Methods: This study was a methodological study. A patient safety culture promotion program, called 'Safe Culture, Save Patients' was developed, based on structuration theory and performance engineering approaches. Results: This program was delivered in the form of a website containing contents about changes in the work environment, information about accidents and the improvement process details, as well as a program for motivation. The program was tested about the validity on contents and usability - a panel of 14 experts confirmed its validity using the contents validity index (CVI), with a resulting S-CVI of .980. Usability was evaluated by 11 nurses, which allowed finalize the program. Conclusion: The 'Safe Culture, Save Patients' program was a valid program that could be applied in clinical practice immediately. The results of this study warrant further studies to evaluate the effects of this patient safety culture promotion program.