환자안전 관리를 위한 위험요인 분석 = Analysis of Risk Factors for Patient Safety Management

다국어 초록 (Multilingual Abstract)

Purpose: This is a pilot study to identify patient safety risk factors and strategies for patient safety management perceived by nurses. Methods: Data were collected and analyzed with an open questionnaire from April to May 2005, targeted on 100 nurses working in two hospitals. The issues were ‘what are risk factors for patients, nurses, and other medical practitioners? How do they prevent with the aftermath of risk factors, causes of incidents?’ For data analysis, types and frequency of risk factors were worked out, using the Australian Incident Monitoring System Taxonomy. Results: The types of patient safety risk factor perceived by nurses were as follows ; therapeutic devices or equipment, infrastructure and services (29.5%), nosocomial infections (16.3%), clinical processes or procedures (15.4%), behavior, human performance, violence, aggression, security and safety (12.2%), therapeutic agents (9.7%), injuries and pressure ulcers (8.7%), logistics, organization, documentation, and infrastructure technology (5.6%). Strategies for patient safety included training of prevention of infection education about safety management for patients and medical professionals, establishment of reporting system, culture of care pre-elimination of risk factors, cooperative system among employees, and sharing information. Conclusion: These results will be used to provide evidences for patient safety management and educational program.

참고문헌 (Reference)

1 김정은, "환자안전 향상을 위한 종합병원의 전산화된 사건보고시스템 운영 실태조사" 10 (10): 379-386, 2004

2 김 윤, "위해사건 감시정보시스템" 10 (10): 211-222, 2004

3 Considine J, "Who, when and where? Identification of patients at a risk of an in-hospital adverse event" 10 : 21-31, 2004

4 Doyle M, "Violence risk assessment" 9 : 649-657, 2002

5 Gallacher,R, "Using guidance to prevent errors when giving blood transfusions" 100 (100): 45-, 2004

6 Institute of Medicine, "To err Is human : building a safer health system" National Academy Press 1999

7 Storch,J.L, "The patient safety movement" 12 (12): 219-220, 2005

8 Glancy G D, "The clinical use of risk Assessment" 50 : 12-17, 2005

9 Andersen K, "Safe use of lasers in the operating room" 79 (79): 171-188, 2004

10 Bleier R A, "Risk prevention means teamwork" 2004

11 Hofler L D, "Public reporting, patient safety, and quality improvement the need for legal protections" 35 (35): 161-162, 2005

12 International Council of Nurses, "Position statement on patient safety" ICN 2002

13 Ballard K A, "Patient safety: a shared responsibility" 8 (8): 2003

14 Kjellberg K, "Patient safety and comfort during transfers in relation to nurses' work technique" 47 (47): 251-259, 2004

15 Byers J F, "Patient safety : principles and practice" Springer publishing Co. 3-, 2004

16 Aspden P, "Patient safety : achieving a new standard for care" National Academy Press 2004

17 O'Connor J, "Nurses' perceptions of critical incidents" 41 (41): 53-62, 2003

18 Farrell G, "Nurses under threat: A comparison of content of 28 aggression management programs" 14 : 44-53, 2005

19 JCAHO, "National patient. safety goals." 2006

20 Huber D, "Leadership & Nursing Care Management" Saunder Co. 2000

21 Page A, "Keeping patients safe : transforming the work environment of nurses" National Academy Press 2004

22 Kettles A, "Is there a relationship between risk assessment and observation level?" 11 : 156-164, 2004

23 Thomas E J, "Incidence and types of adverse events and negligent care in Utah and Colorado" 38 (38): 261-271, 2000

24 Milligan F, "Improving patient safety and incident reporting" 19 (19): 33-36, 2004

25 Reason J, "Human error: models and management" 320 : 768-770, 2000

26 Heath J, "Healthy work environments" 34 (34): 524-530, 2004

27 Tomey A M, "Guide to Nursing Management & Leadership" Mosby 412-, 2000

28 Neale G, "Exploring the cause of adverse events in NHS hospital practice" 94 (94): 322-330, 2001

29 Pronovost P J, "Evaluation of the culture of safety" 12 : 405-410, 2003

30 Weingart S N, "Epidemiology of medical error" 320 : 774-777, 2000

31 Petersen C, "Compressed medical gases" 80 (80): 1129-1133, 2004

32 Lin L, "Comparison of risk management in Taiwan and the USA" 14 : 222-226, 2006

33 Lingard L, "Communication failures in the operating room" 13 : 330-334, 2004

34 McIlwain J C, "Clinical risk management: principles of consent and patient information" 24 : 255-261, 1999

35 Kerzman H, "Characteristics of falls in hospitalized patients" 47 (47): 223-229, 2004