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KMID : 1031020230290020015
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Quality Improvement in Health Care
2023 Volume.29 No. 2 p.15 ~ p.31
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Characteristics of Nursing-related Patient Safety Incidents and Qualitative Content Analysis: Secondary data Analysis of Medical Litigation Judgment (2014~ 2018)
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Kim Min-Ji
Lee Won
Kim Sang-Hee
Kim So-Yoon
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Abstract
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Purpose: This study aimed to identify the characteristics of patient safety incidents (PSIs) related to nursing and to provide primary data for preventing the recurrence of similar incidents.
Methods: This secondary analysis study included damage claims rulings filed for clinical negligence from 2014 to 2018 that contained the keyword ‘nurse’. It excluded judgments irrelevant to nursing care and in which clinical negligence or causal damages were overruled. A total of 93 cases were analyzed. The characteristics of PSIs were derived through descriptive statistics, and two instances of nursing-related PSIs were examined by qualitative content analysis focusing on root causes.
Results: The analysis of PSIs related to nursing suggested that the medical institutions where the PSIs occurred most frequently were hospitals, and the most common types of PSIs were medication, surgery, and treatment/procedure, in that order. In addition, it indicated that nursing-related PSIs occurred most frequently in general wards during the day shift, with the most common related nursing practice being managing potential risk factors. The qualitative analysis showed that careless monitoring and institutional inertia were causes of PSIs.
Conclusion: To prevent nursing-related PSIs, nurses need to individually monitor and assess patient conditions. In addition, support should be accompanied by the improvement in the systems in place aimed at preventing the recurrence of nursing-related PSIs at the institutional and national level, such as securing appropriate nursing personnel and improving labor conditions.
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KEYWORD
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Patient safety, Nursing, Root cause analysis, Risk management, Jurisprudence
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