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의료사고의 근본원인 분석 : 의료사고 판례문 이용

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Root Cause Analysis of Medical Accidents - Using Medical Accident Cases

김선녀, 조덕영

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초록

영어

Objectives: To investigate whether medical institutions can prevent accidents by analyzing the root cause of a medical accident and identifying the tendencies. Methods: A total of 345 medical cases were used for the RCA(Root Cause Analysis). The root causes were classified using the SHELL model. The suitability of the model was confirmed by SPSS's MDPREF and Euclidean distance. An SPSS20.0 hierarchical regression analysis was used as an influencing factor on the degree of injury resulting from medical accidents. Results: The SHELL model was suitable for classification. The rates of accident causes were LS49%, L34%, LL10.2%, LE3.7%, LH2.3%. The order in which the degree of a patient’s injury was affected were: Risk Threshold (ꞵ=.180), Time (ꞵ=.175), Surgical stage (ꞵ=-.166), Do not use procedure (ꞵ=.147). Conclusions: Health care institutions should remove priorities through system improvement and training. For patients’ safety, the five factors of the SHELL model should be managed in harmony.

목차


Ⅰ. 서론
1. 연구의 필요성
2. 연구목적
Ⅱ. 연구방법
1.연구 설계
2.연구대상과 자료수집
3.자료의 분석방법
Ⅲ. 연구결과
1.연구의 일반적 특성
2.도출된 의료사고의 근본원인과 SHELL 모델의 범주별 결과
3. SHELL 모델의 타당성 분석
4. 의료기관 특성 및 근본원인 요인과 상해정도의 차이
5. 상해정도에 영향을 주는 요인
6. 상해정도에 영향을 주는 요인의 위계적 회귀분석
Ⅳ. 고찰
V. 결론
REFERENCES

저자정보

  • 김선녀 Seon-Nyeo KIM. 부산대학교 의료경영연구소
  • 조덕영 Duk-Young Cho. 부산대학교 의학전문대학원

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