• Safety and Health at Work
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• v.4 no.4
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• pp.210-215
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• 2013

Background: This study aimed to identify the impacts of job stress and cognitive failure on patient safety incidents among hospital nurses in Korea. Methods: The study included 279 nurses who worked for at least 6 months in five general hospitals in Korea. Data were collected with self-administered questionnaires designed to measure job stress, cognitive failure, and patient safety incidents. Results: This study showed that 27.9% of the participants had experienced patient safety incidents in the past 6 months. Factors affecting incidents were found to be shift work [odds ratio (OR) = 6.85], cognitive failure (OR = 2.92), lacking job autonomy (OR = 0.97), and job instability (OR = 1.02). Conclusion: Patient safety incidents were affected by shift work, cognitive failure, and job stress. Many countermeasures to reduce the incidents caused by shift work, and plans to reduce job stress to reduce the workers' cognitive failure are required. In addition, there is a necessity to reduce job instability and clearly define the scope and authority for duties that are directly related to the patient's safety.

• 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.

• 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.

• Journal of Korean Clinical Nursing Research
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• v.26 no.2
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• pp.131-140
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• 2020

Purpose: This study aims to describe the characteristics of safety incidents and factors associated with injury for patients with Home Mechanical Ventilation (HMV) at the hospital. Methods: This is a retrospective study. Data were collected from the work log of respiratory home care nurses and the patients' electronic medical records were investigated. In order to compare group differences, independent t-test and χ² test were used. Associated factors with injury development were identified by generalized mixed modeling analysis controlling for age and gender. Results: A total of 304 patients on HMV were included in this study, among which 129 (42.4%) experienced 352 HMV-related incidents. Mean frequency of incidents for each patient was 5.11±3.98, ranged from 1 to 15 times. In 19.0% of the incidents, injury was developed. Types of incident and persons involved in the incidents were significantly associated with the patient's injury. In the case of the safety incidents, patient's injury was significantly higher in accidents caused by respiratory circuit problems compared to those caused by problems with the ventilator operation by the medical staff (coefficient=1.25, p=.020). In addition, in the case of those involved in the safety incidents, patient's injury was significantly higher in the accident caused by the patient family members or caregivers than that caused by the medical personnel (coefficient=1.25, p=.019). Conclusion: In order to minimize injury caused by incidents in patients with HMV, hospitals need to provide systemic education to their medical staff and caregivers to enhance awareness of the importance of reporting and safety management.

• Quality Improvement in Health Care
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• v.24 no.1
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• pp.9-22
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• 2018

Purpose: The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods: We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results: The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion: The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea.

• Journal of Korean Critical Care Nursing
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• v.13 no.2
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• pp.1-11
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• 2020

Purpose : The aim of this study was to compare shift satisfaction, sleep, fatigue, quality of life (QOL), and patient safety incidents between a newly implemented two-shift system and a traditional three-shift system. Methods : A total of 127 intensive care unit nurses (48 two-shift nurses and 79 three-shift nurses) working in a tertiary hospital in Seoul were recruited from January 1, 2017, to March 31, 2017. They completed a self-reported questionnaire about their work hours, shift satisfaction, sleep patterns, sleep quality, fatigue, QOL, and patient safety incidents in the past 2 weeks. Data were analyzed using SPSS version 23.0. Results : The two-shift group showed higher shift satisfaction scores compared with the three-shift group (6.93 vs. 4.37, p<.001). Sleep latency was shorter and sleep quality was better in the two-shift group compared with the three-shift group. There were no significant differences in other sleep parameters, fatigue, QOL, and patient safety incidents between the two groups. Conclusion : Although a two-shift system did not improve nurses' fatigue or QOL in this study, it may effectively serve as an alternative shift-work system that can increase sleep quality and shift satisfaction without increasing patient safety incidents.

• Quality Improvement in Health Care
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• v.23 no.1
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• pp.11-23
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• 2017

Root Cause Analysis (RCA) has been widely used as a structured approach to investigate patient safety incidents. RCA helps identify what, how, and why something happened, therefore preventing recurrence of incidents. Since many quality tools can be used during RCA, various formats of RCA exist. If RCAs are performed incorrectly or incompletely, they are likely to produce unusable results. To address this issue, RCA software has been developed. The use of RCA software in investigating patient safety incidents may offer several advantages, such as potential reduction in learning time, shortening of the analytic process, facilitation of collection, analysis, and presentation of data and production of meaningful RCA reports. We introduced six healthcare RCA software and compared characteristics. Results from this study will enable the RCA team to choose proper RCA software.

• Journal of Preventive Medicine and Public Health
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• v.50 no.2
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• pp.68-82
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• 2017

Objectives: We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI). Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. Results: There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. Conclusions: The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.19 no.12
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• pp.374-382
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• 2018

The aim of this study was to identify how information media about patient safety incidents influences nursing students' knowledge, perception, and confidence in performance toward patient safety. A total of 337 nursing students agreed to participate in this study. Data were collected from the participants between June 4 and June 12, 2018. Data were analyzed using descriptive statistics, t-test, one-way ANOVA, and Pearson's correlation coefficient with SPSS 21.0. Participants' scores for knowledge, perception, and performance confidence toward patient safety were $6.43{\pm}1.92$, $41.02{\pm}4.35$, and $39.61{\pm}5.89$, respectively. Patient safety knowledge was significantly different according to age, grade, and patient safety education experience. Patient safety perception was significantly different according to satisfaction with the major, patient safety performance confidence showed statistically significant differences according to grade, patient safety education experience, and major satisfaction. Information media exposure to patient safety incidents on TV and knowledge (r=.32, p<.000) and performance confidence (r=.21, p<.000) toward patient safety had positive correlations. Information media exposure to patient safety incidents on the internet and knowledge (r=.34, p<.000), perception (r=.12, p=.028), and performance confidence (r=.24, p<.000) toward patient safety also had positive correlations. This study provides basic data for nursing education and program development for patient safety management.

• Journal of radiological science and technology
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• v.47 no.4
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• pp.287-294
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• 2024

Radiation oncology departments are at high risk for potential radiation safety incidents. This study aimed to identify risk factors for these incidents using the P-mSHEL (Patient, Management, Software, Hardware, Environment, and Liveware) model and to evaluate potential accident types through Failure Mode and Effects Analysis (FMEA). FMEA identified seven accident types with high Risk Priority Number (RPN). A total of 56 detailed risk factors were classified using the P-mSHEL model, and measures to prevent radiation safety incidents were implemented. The effect of these preventive measures on workers' safety perception was confirmed through two indicators (FMEA and safety perception). After implementing the preventive measures, the FMEA analysis showed that the highest reduction in RPN was for A-6 (radiation exposure while other patients/guardians are present) with a reduction rate of 33.3%, followed by B-3 (radiation exposure while staff are present) with a reduction rate of 33.3%. Overall safety perception significantly improved after the preventive measures (4.17±0.35) compared to before (2.76±0.33) (p<0.05), with notable increases in both employee safety culture (3.93±0.51) and patient safety culture (3.73±0.62) (p<0.05). This study identified risk factors in radiation oncology departments. Continuous management, maintenance, and fostering a strong safety culture are crucial for preventing incidents. Regular problem identification and collaboration with relevant departments are essential for maintaining safety standards.