Prevention ; System ; Use of ; Approaches ; Medical Errors

Accident Prevention ; Humans ; Malpractice ; Medical Errors ; prevention & control ; Surgical Procedures, Operative

Bone Screws ; adverse effects ; Humans ; Medical Errors ; prevention & control ; Models, Biological ; Scoliosis ; surgery ; Thorax

Electricity ; Electrosurgery ; instrumentation ; Equipment Design ; Equipment Safety ; methods ; standards ; Guidelines as Topic ; Medical Errors ; prevention & control ; Surgical Equipment ; standards

Pituitary apoplexy is a rare, life-threatening complication that may occur after coronary artery bypass graft surgery for patients with pituitary adenomas. The dynamics of cardiopulmonary bypass may contribute to a sudden expansion of silent pituitary adenomas and result in the compression of surrounding structures. A range of clinical features have been described, and the condition requires prompt diagnosis and treatment to prevent further complications. Herein, we present an uncomplicated case highlighting the importance of diagnosing pituitary apoplexy, ensuring high alertness to the condition, so as to prevent life-threatening tragedy due to missed diagnosis.
Aged ; Cardiopulmonary Bypass ; adverse effects ; Coronary Artery Bypass ; adverse effects ; methods ; Hemodynamics ; Humans ; Male ; Medical Errors ; prevention & control ; Monitoring, Physiologic ; methods ; Pituitary Apoplexy ; complications ; prevention & control ; Pituitary Neoplasms ; complications ; Postoperative Complications ; prevention & control ; Risk Assessment ; Treatment Outcome

PURPOSE: The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. METHODS: A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. RESULTS: The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. CONCLUSION: Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.
Adult ; Double-Blind Method ; Female ; Humans ; *Internet ; Korea ; Medical Errors/*prevention & control/statistics & numerical data ; *Operating Room Nursing ; Risk Management/*methods ; *Staff Development ; Statistics, Nonparametric

PURPOSE: The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. METHODS: A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, chi-square-test, t-test, and ANCOVA with the SPSS 12.0 program. RESULTS: After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, p<.001). There was no significant difference in some categories for organizational culture and intention to report. CONCLUSION: The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.
Adult ; Attitude of Health Personnel ; Humans ; Internet ; Medical Errors/*nursing/prevention & control ; Nursing Staff, Hospital/organization & administration/*psychology ; Organizational Culture ; Patient Care ; Program Evaluation ; Questionnaires ; Risk Management ; Young Adult

The concept of medical devices adverse events is introduced in the paper. The contents of surveillance of adverse events are discussed and the government's role in the surveillance is presented as well.
Equipment Failure ; Equipment Safety ; Equipment and Supplies ; Government Agencies ; Medical Errors ; prevention & control ; Product Surveillance, Postmarketing ; Risk Factors ; Safety Management ; methods ; Social Responsibility

OBJECTIVE: To study the rules of forensic expertise on medical disputes in obstetrics and gynecology, and the characteristics of medical faults in order to provide theoretical supports for forensic expertise. METHODS: Eighty two cases of forensic expertise on medical disputes in obstetrics and gynecology were respectively analyzed, which were performed in Forensic Science Center of West China from 2002 to 2008. RESULTS: It has been found that cases of forensic expertise on medical disputes in obstetrics and gynecology were increasing year by year, with more dispute cases from municipal (district) and county hospitals than other hospitals. More disputes involved in childbearing and surgery cases. The main reasons of the medical faults were due to defects of medical techniques and managements. CONCLUSION The forensic expertise of medical dispute must focus on the corresponding clinical regulations and whether the doctor fulfill their obligations. Meanwhile, whether there are physician negligence, technique faults and management defects should be investigated.
Adult ; Expert Testimony ; Female ; Forensic Medicine ; Gynecology ; Humans ; Malpractice/statistics & numerical data* ; Medical Errors/prevention & control* ; Obstetrics ; Pregnancy ; Professional Misconduct ; Retrospective Studies

OBJECTIVE: To explore the main problems and ideas in the death cases of medical tangles after trauma. METHODS: Twelve death cases of medical tangles after trauma were selected from a forensic science institute during recent six years. Traumatic conditions, medical malpractices and contribute degree of malpractice were estimated and analyzed. RESULTS: The reasons of trauma included accidents and intentional injury. Among these cases, there were 10 involved in malpractice, of which 7 cases played secondary role. CONCLUSION Diagnosis, symptom observation and emergency therapy are the important keys for determining the responsibility in death cases of medical tangles after trauma.
Adult ; Aged ; Cause of Death ; Female ; Forensic Medicine ; Fractures, Bone/pathology* ; Humans ; Male ; Malpractice ; Medical Errors/prevention & control* ; Middle Aged ; Retrospective Studies ; Wounds and Injuries/pathology* ; Young Adult