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Analysis of Patient Safety Incident in Korea

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KMID : 0614820200260020151
±è³²ÀÌ ( Kim Nam-Yi ) - ´ëÀü°úÇбâ¼ú´ëÇб³ °£È£Çаú

Abstract

¸ñÀû: º» ¿¬±¸ÀÇ ¸ñÀûÀº Çѱ¹ÀÇ ¡¯2018³â ȯÀÚ¾ÈÀüº¸°í µ¥ÀÌÅÍ¡¯¸¦ ºÐ¼®ÇÏ¿© ȯÀÚ¾ÈÀü»ç°í¿Í °ü·ÃµÈ ¿äÀÎÀ» ºÐ¼®ÇÏ°í, ȯÀÚ¾ÈÀü»ç°í ¿¹¹æ ¹× ÁßÀç ¹æ¾ÈÀ» ¸¶·ÃÇϴµ¥ ÀÖ´Ù.

¹æ¹ý: 2019³â¿¡ ¹ßÇ¥µÈ ¡®2018³â ȯÀÚ¾ÈÀüº¸°í µ¥ÀÌÅÍ¡¯¿¡ ´ëÇØ ºÐ¼®ÇÏ¿´´Ù. 2018³â¿¡ 9,250°ÇÀÇ È¯ÀÚ¾ÈÀü»ç°í°¡ º¸°íµÇ¾úÀ¸¸ç, 500º´»ó ÀÌ»ó º´¿øÀÇ µ¥ÀÌÅÍ 3,757°ÇÀ» ºÐ¼®ÇÏ¿´´Ù. SPSS 25.0À» ÀÌ¿ëÇÏ¿© ±³Â÷ºÐ¼® ¹× ´ÙÇ× ·ÎÁö½ºÆ½ ȸ±ÍºÐ¼®À» ÇÏ¿´´Ù.

°á°ú: Àû½ÅÈ£»ç°Ç¿¡ ¿µÇâÀ» ¹ÌÄ¡´Â ¿äÀÎÀº ¾ø¾ú´Ù. À§ÇØ»ç°ÇÀÇ °æ¿ì ¿¬·É, ÀÔ¿ø½Ç, Ä¡·á½Ç, °£È£»çÀÇ ³· ±Ù¹« ½Ã°£, ³«»ó, ¼öÇ÷ ¹× ¾à¹°ÀÌ ÁÖ¿ä ¿äÀÎÀ̾ú´Ù.

°á·Ð: ȯÀÚ¾ÈÀü»ç°í¸¦ ¿¹¹æÇϱâ À§ÇØ È¯ÀÚÀÇ ¿¬·ÉÀÌ ¸¹Àº °æ¿ì ¾ð¾îÀû, ºñ¾ð¾îÀû ÀÇ»ç¼ÒÅë¿¡ ±Í¸¦ ±â¿ïÀÌ°í, Áúº´ÀÇ º¹ÇÕ¼ºÀ» ÀÌÇØÇÏ°í ÀÌ¿¡ ´ëÇÑ Áö½ÄÀ» °®Ãß¾î¾ß ÇÑ´Ù. ¶ÇÇÑ °£È£»çÀÇ ÃÊ°ú±Ù¹«¸¦ ÁÙÀ̵µ·Ï ÇÏ´Â ±Ù¹«È¯°æ °³¼±ÀÌ ÇÊ¿äÇϸç, ȯÀÚ ¸ð´ÏÅ͸µ ½Ã½ºÅÛ°ú ³«»ó¿¹¹æÈ°µ¿, ȯÀÚ¾ÈÀü±ÔÁ¤°ú ÀýÂ÷¸¦ Àü»êÈ­ÇÏ¿© ÀÎÀû ¿À·ù¸¦ ÁÙÀÏ ¼ö ÀÖ´Â ¹æ¾ÈÀ» ¸ð»öÇØ¾ß ÇÒ °ÍÀÌ´Ù.

Purpose: The purpose of this study was to analyze factors related to patient safety incidents by analyzing ¡¯2018 patient safety report data¡¯ for Korea, and to prepare a plan for preventing patient safety incidents.

Methods: Analysis was done for 2018 patient safety report data¡¯published in 2019. In 2018, 9,250 patient safety incidents were reported, and for this study data (3,757) from hospitals with more than 500 beds were analyzed. SPSS 25.0 was used for the crosstabulation analysis and multinominal logistic regression.

Results: There were no factors affecting the sentinel event. The main factors of adverse events were age, patient room, treatment room, day duty of nurses, falls, transfusions, and medication.

Conclusion: In order to prevent patient safety incidents, elderly patients should receive verbal and nonverbal communication that will help them understand the complexity of the disease. Finding ways to reduce nurse overtime and reduce human error by computerizing patient monitoring systems, fall prevention activities, and patient safety regulations and procedures are necessary.
KeyWords
ÀÇ·á¿À·ù, ȯÀÚ¾ÈÀü, º¸°ÇÀÇ·áµ¥ÀÌÅÍ °ø°³º¸°í, ¾ÈÀü°ü¸®
Medical error, Patient safety, Public reporting of healthcare data, Safety management
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ÇмúÁøÈïÀç´Ü(KCI) KoreaMed