No abstract available.
Humans ; Medical Errors ; Patient Safety

This paper introduced and classify the common mistakes in the study and use of pharmaceutical materials including mistakes due to the same form, due to the processing that changed the primary form of materials, casual distribution of materials, identical name, identification of botanical resources, imitate materials and lack of knowledge of material resources.
Pharmacy ; Medical Errors ; Drug Industry

Prevention ; System ; Use of ; Approaches ; Medical Errors

PURPOSE: Through the analysis of orthopedics lawsuit rulings, the purpose of this study is to understand the current trends of medical lawsuits in orthopedics in Korea. MATERIALS AND METHODS: An analysis of medical lawsuits in orthopedics was conducted. As the study method, a quantitative analysis was performed on 341 cases. RESULTS: The average period of lawsuits, from the occurrence of the medical accident to end of the ruling, took an average of 4.22 years. The most frequent procedure that was the main cause of the medical accidents was surgery, at 46.3%. When surgery is the main procedure that caused the medical accidents, the result of examining the types of surgeries showed that spine surgery had the highest percentage. For the outcome of the accident, the highest number of cases resulted in disability and for the final court outcome, 40.5% ruled partially in favor of the plaintiff (the patient) with acknowledgement of only the damage incurred due to medical error of the total sum claimed, and dismissal of the claim made by the plaintiff (patient) accounted for 34.3%; 26.1% of cases develop infection. For the amount of claim for damage, the average amount of claim was 181,998,036 won; in the judgement amount, the average amount of judgement was 58,897,161 won. CONCLUSION: The most frequent procedure in orthopedics was surgery and spine surgery comprised a large proportion of these surgeries. Future studies to determine root causes of medical accidents should be conducted to reduce medical lawsuits and to plan against the repeating of medical accidents.
Korea* ; Medical Errors ; Methods ; Orthopedics* ; Spine

Medication errors such as administration of wrong drugs, wrong dosage and erroneous route of administration are not rare among medical misadventures. We present an autopsy case of accidental injection of tranexamic acid instead of bupivacaine during spinal anesthesia, accompanying the quantitative result of the tranexamic acid in the blood, cerebrospinal fluid and each internal organs. We think that warning signs on syringes and ampoules, simple and unified guideline for drug administration, separative documentation of drug administration and interpersonal communication on drug information should be done to prevent this type of medical errors.
Anesthesia, Spinal ; Autopsy ; Bupivacaine ; Medical Errors ; Medication Errors ; Syringes ; Tranexamic Acid

OBJECTIVE: To identify the technical considerations in implementing a barcode-based medication system and propose practical solutions for successful implementation of the system. In order to reduce medical errors related to medication and blood transfusion, we analyze various factors that hinder the successful implementation of the barcode-based medication system and discuss issues involved in the effective adoption of such a system. METHODS: The barcode-based medication system of this research uses one-dimensional, barcode bands on patients' wrists and two-dimensional barcodes attached to drug bags and blood bags. PDAs with barcode reading capability and wireless networking function are used, which enables Point of Care. The business process for applying the developed system and the current status of the system usage are analyzed. RESULTS: The factors causing a variety of system failures in the demonstration and pilot periods were identified and categorized as including PDA malfunction, PDA battery discharge due to users' carelessness, confusion in reading barcodes and so on. CONCLUSIONS: It is expected that the analyzed obstructive factors and the proposed technical considerations addressed in this paper can help other hospitals implement similar barcode-based medication systems successfully. Ultimately, this research will contribute to reducing medical errors and improving quality of patient care.
Adoption ; Blood Transfusion ; Commerce ; Medical Errors ; Medication Errors ; Medication Systems ; Patient Care ; Wrist

PURPOSE: The emergency department is prone to medical errors due to the patients'acuity and complexity. Collection and monitoring of data on medical errors are essential for setting priorities and improving patient safety. METHODS: Emergency physicians report medical errors voluntarily with an intranet-based error reporting system. The system is confidential and anonymous. Data on medical errors was collected at the emergency department of a tertiary teaching hospital with approximately 76,000 annual visits, during a nine-month period from April to December 2008. The collected data was analyzed prospectively. RESULTS: Of the 238 reports collected, 204 errors were analyzed. 90.6% of the errors were related to doctors and 21% were related to nurses. Error types were classified into clinical errors (57%), medication errors (7%) and administrative errors (35%). The levels of impact on patients caused by these errors were classified as near-miss in 28 (13%), no harm in 93 (45%), mild harm in 66 (32%), lethal in 5 (2%) and death in 2 (1%) cases. Errors that occurred in the elderly group (over 60 years of age) had more harmful impact than in other age groups (p=0.0003). The causes of these errors were human in 147 (72%), systems in 23 (11%) and both human and systems in 34 (17%). Most of these errors were preventable (99%). CONCLUSION: Data collected by the intranet-based medical error reporting system is useful to classify and analyze medical errors, and is also essential in the implementation of a patient safety system.
Aged ; Anonyms and Pseudonyms ; Emergencies ; Emergency Medicine ; Hospitals, Teaching ; Humans ; Medical Errors ; Medication Errors ; Patient Safety

Adult ; Bone and Bones ; injuries ; Diagnostic Errors ; Fractures, Bone ; diagnosis ; therapy ; Humans ; Male ; Medical Errors ; Young Adult

PURPOSE: To predict the accuracy of preoperative refractive error measurement methods in wavefront-guided laser-assisted subepithelial keratectomy (LASEK) surgery and to formulate a nomogram for satisfactory surgical results. METHODS: The medical records of 30 patients (57 eyes) who had undergone wavefront-guided LASEK were reviewed. The ideal surgical ablation amount was defined as the sum of the real surgical ablation amount and the remaining refractive errors. Comparison between the ideal surgical ablation amount and preoperative refractive errors was made using autorefraction, manifest refraction, cycloplegic refraction, postcycloplegic refraction, wavescan, and iTrace aberrometer measurements. RESULTS: The refractive errors measured by the postcycloplegic refraction showed the closest relation with the ideal surgical amount, and the nomogram based on this refraction correlated statistically significantly with the ideal surgical ablation amount. The refractive error using the wavescan also showed more accurate refractive measurements than the autorefractor and iTrace aberrometer. CONCLUSIONS: Accurate manifest refraction immediately before surgery is the most important in determining the ablation amount. Additionally, the refractive errors measured with the wavescan, which is an aberrometer used for wavefront-guided LASEK, showed a minimal amount of errors. After reviewing the results, the nomogram based on these 2 methods can be concluded to possibly contribute to an increase in the accuracy of surgery.
Humans ; Keratectomy, Subepithelial, Laser-Assisted ; Medical Records ; Nomograms ; Refractive Errors

PURPOSE: To investigate which factors are associated with the causes and results of medical malpractice claims on emergency medical facilities. The study analyzed the alteration of judicial precedents between before and after 1995 when the court ruled that the burden of proof was to be placed upon the accused as well as the plaintiff. METHODS: We collect 213 medical malpractice claims covering from 1953 to 2008, using a database of closed claims maintained by the Supreme Court of Korea. Of the 213 claims, 31 involved emergency medical facilities. The cases were divided into 4 groups according to the physician's specialty and the causes and results of the claims were compared among each group. The causes and results were also compared between before and after 1995. RESULTS: In the medical department, the physicians were mainly accused in connection with mis- or delayed diagnosis. In the surgical and emergency departments, the plaintiff denounced the physician generally for neglect of duty in the emergency medical service system. The tendency of the court's ruling related to the distribution of the burden of proof has been changed after 1995 and the rate of physician legal victory in the judicial precedents has declined since then. CONCLUSION: Medical malpractice claims on emergency medical facilities were mostly related to misdiagnosis or emergency medical service system. Due to the change in the court's ruling regarding the distribution of the burden of proof, emergency physicians with medical malpractice claims need to change their attitude with regards to the activeness in the claims.
Delayed Diagnosis ; Diagnostic Errors ; Emergencies ; Emergency Medical Services ; Korea ; Malpractice