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의료사고의 근본원인 분석: 의료사고 판례문 이용

Root Cause Analysis of Medical Accidents -Using Medical Accident Cases

보건의료산업학회지 2019년 13권 3호 p.13 ~ 26
김선녀 ( Kim Seon-Nyeo ) - 부산대학교 의료경영연구소

조덕영 ( Cho Duk-Young ) - 부산대학교 의학전문대학원


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 (β=.180), Time (β=.175), Surgical stage (β=-.166), Do not use procedure (β=.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


의료사고; 근본원인분석; 환자안전; SHELL 모델
Medical accident; Root Cause Analysis; Patient Safety; SHELL model
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