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논문분류	춘계학술대회 초록집
제목	Patient safety problems in the nephrology field of a university hospital setting : analysis of 6 year’s events
저자	Hyuck Jae Choi* 1, Seok Bo Hong1, Sang-Ho Jeong1, Seun Deuk Hwang1, Seoung Woo Lee1
출판정보	2016; 2016(1):
키워드	ESRD patients, Patient safety
초록	Background: Patients who admitted to the nephrology were at high risk for safety events because of the complexity of their care, old age and comorbid conditions. A study was planned in order to prevent what the types of these malpractices. Methods: To investigate the characteristics of safety events in the nephrology field, we analyzed the reported events from Jan, 2010 to March, 2016. The causes of events were classified into 9 groups: drug-related event, fall, diagnostic examination-related event, procedure-related event, treatment-related event, body injury, security, operating procedure-related event, and others. Patient outcome were classified as follows; near miss, adverse event, and sentinel event. The adverse event was an event which reached a patient with no harm or transient harm. The sentinel event was an event which resulted in permanent damage to a patient or death. Results: There were 89 events from 73 patients. The mean age was 65±13 years, male was 37 (50.6%), diabetes was 38 (52.8%) and end-stage renal disease (ESRD) on dialysis were 62 (84.9%)(hemodialysis : peritoneal dialysis = 56: 6). Among 89 events, the most common cause of safety events was treatment-related one (32.6%). The next was drug-related events (23.6%), others (15.7%), diagnostic examination-related events(14.6%), procedure-related events(10.1%), and fall (3.4%), in order. When restricted to ESRD patients, the most common cause was treatment-related events (40.3%), in which treatment error (failure to carry out a planned action as intended or application of an incorrect plan) was 80%. The next was drug-related events (19.4%), in which general medicine-related event was 83%. Among 89 events, near miss, adverse events, and sentinel events were 23.6%, 73.0%, and 3.4%, respectively. In hamful event and cause of accident, There were no significant differences between the ESRD and non-ESRD patients.(P=0.239) Conclusion: In conclusion, many patient safety events were reported in the ESRD patients on dialysis and 79% were harmful event, suggesting ESRD patients as high risk group of safety.
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