---
id: rihp-research-report-2026-02-s08
title: "참고문헌"
collection: research-report
publication_id: 2026-02
year: 2026
published_at: "2026-07-09"
category: "chapter"
authors: ["안지현", "김우진"]
topics: []
pdf_pages: 195-206
source_file: "rihp-research-report-2026-02.pdf"
source_sha256: 6690de800154191dd8ebc868c4c9b50f7fad657a4276d495c3ace97b9e1bce7b
source_url: "https://rihp.re.kr/bbs/board.php?bo_table=research_report&wr_id=388"
pdf_url: "https://rihp.re.kr/bbs/download.php?bo_table=research_report&wr_id=388&no=1"
extraction_status: machine-extracted-needs-review
ai_generated_metadata: true
---

# 참고문헌

> [!CAUTION] 기계 추출 파일럿입니다. 표·그림·문서 경계를 원본 PDF와 대조해야 합니다.
> 원문의 필자 개인 견해 고지가 있는 경우 기관의 공식 견해로 해석하지 않습니다.

## 출처

- 발간물: 의원급 의료기관의 환자안전사고 예방 및 대처를 위한 방안
- PDF 물리 페이지: 195-206
- 원본 파일: `rihp-research-report-2026-02.pdf`
- RIHP 게시물: [https://rihp.re.kr/bbs/board.php?bo_table=research_report&wr_id=388](https://rihp.re.kr/bbs/board.php?bo_table=research_report&wr_id=388)
- RIHP PDF: [https://rihp.re.kr/bbs/download.php?bo_table=research_report&wr_id=388&no=1](https://rihp.re.kr/bbs/download.php?bo_table=research_report&wr_id=388&no=1)

## 정규화 본문

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참고문헌

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참고문헌
1. 국내 문헌
대한소화기학회. 의료분쟁사례집. 서울: 대한소화기학회; 2025.
보건복지부. 제2차 환자안전종합계획(2023–2027). 세종: 보건복지부; 2023.
의료기관평가인증원 중앙환자안전센터. 2023년 환자안전 통계연보. 서울: 의료기관평가인증원;
2024.
의료기관평가인증원 중앙환자안전센터. 2024 환자안전 연계보고서. 서울: 의료기관평가인증원;
2024.
조우신. 근골격계 진료에서 흔한 의료사고와 예방. In: 대한재활의학과의사회 2026 춘계학술
대회; 서울. 서울: 메디멤버스; 2026. p.173-175.
질병관리청. 예방접종 실시 기준 및 방법에 관한 고시. 세종: 질병관리청; 2024.
2. 국외 문헌
ACR Committee on Drugs and Contrast Media. ACR manual on contrast media. 2024
ed. Reston (VA): American College of Radiology; 2024.
ACR Committee on MR Safety; Greenberg TD, Hoff MN, Gilk TB, Jackson EF, Kanal
E, McKinney AM, et al. ACR guidance document on MR safe practices: updates
and critical information 2019. J Magn Reson Imaging. 2020;51(2):331-8.
Al Lawati MH, Dennis S, Short SD, Abdulhadi NN. Patient safety and safety culture
in primary health care: a systematic review. BMC Fam Pract. 2018;19(1):104.
Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth.
1995;7(1):89-91.
American Heart Association. Highlights of the 2020 American Heart Association
guidelines for CPR and ECC. Dallas (TX): AHA; 2020.
American Society of Anesthesiologists Task Force on Moderate Procedural Sedation
and Analgesia; American Association of Oral and Maxillofacial Surgeons;
American College of Radiology; American Dental Association; American
Society of Dentist Anesthesiologists; Society of Interventional Radiology.
Practice guidelines for moderate procedural sedation and analgesia 2018.
Anesthesiology. 2018;128(3):437-79.
American Society of Anesthesiologists Task Force on Sedation and Analgesia by
177

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의원급 의료기관의 환자안전사고 예방 및 대처를 위한 방안
Non-Anesthesiologists. Practice guidelines for sedation and analgesia by
non-anesthesiologists. Anesthesiology. 2002;96(4):1004-17.
American Society of Anesthesiologists. Standards for basic anesthetic monitoring
[Internet]. Schaumburg (IL): ASA; 2020 [cited 2025 Dec 1]. Available from:
https://www.asahq.org/standards-and-practice-parameters
Anderson MJ, Stephens WA, Levy BE, Newcomb MR, Harris AM. Barriers to incident
reporting by physicians: a survey of surgical residents and attending
physicians. Cureus. 2024;16(6):e62850.
Auraaen A, Slawomirski L, Klazinga N. The economics of patient safety in primary
and ambulatory care: flying blind. Paris: OECD Publishing; 2018 (OECD Health
Working Papers No. 106). Available from:
https://doi.org/10.1787/baf425ad-en
Australian Commission on Safety and Quality in Health Care. Australian open
disclosure framework. Sydney: ACSQHC; 2013.
Carayon P, Schoofs Hundt A, Karsh BT, Gurses AP, Alvarado CJ, Smith M, et al. Work
system design for patient safety: the SEIPS model. Qual Saf Health Care.
2006;15(Suppl 1):i50-8.
Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R,
et al. Human factors systems approach to healthcare quality and patient
safety. Appl Ergon. 2014;45(1):14-25
Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et
al. World Allergy Organization anaphylaxis guidance 2020. World Allergy
Organ J. 2020;13(10):100472.
Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, et al.
Characterising the nature of primary care patient safety incident reports in
the England and Wales National Reporting and Learning System: a
mixed-methods agenda-setting study for general practice. Health Soc Care
Deliv Res 2016;4(27).
Centers for Disease Control and Prevention. Interim Considerations: Preparing for
the Potential Management of Anaphylaxis after COVID-19 Vaccination.
Atlanta, GA: Centers for Disease Control and Prevention; 2021. Available from
178

<a id="page-199"></a>

### PDF p.199

참고문헌
https://stacks.cdc.gov/view/cdc/106313
Centers for Disease Control and Prevention. STEADI (Stopping Elderly Accidents,
Deaths & Injuries): toolkit for healthcare providers. Atlanta (GA): CDC; 2016
[updated 2024]. Available from:
https://www.cdc.gov/steadi/index.html
Centers for Disease Control and Prevention. Vaccine storage and handling toolkit.
Atlanta (GA): CDC; 2024.
Cho H, Kwon JW. Prevalence of anaphylaxis and prescription rates of epinephrine
auto-injectors in urban and rural areas of Korea. Korean J Intern Med.
2019;34(3):643-50.
Cho H, Woo YH, Park SK. The 2nd National Action Plan for Prevention and Control
of Healthcare-Associated Infections (2023–2027). Public Health Wkly Rep.
2024;17(13):521-31.
Choi EY, Pyo J, Park YK, Ock M, Kim S. Development of the Korean Patient Safety
Incidents Code Classification System. J Patient Saf. 2022;19(1):8-14.
Davenport MS, Perazella MA, Yee J, Dillman JR, Fine D, McDonald RJ, et al. Use of
intravenous iodinated contrast media in patients with kidney disease:
consensus statements from the American College of Radiology and the
National Kidney Foundation. Radiology. 2020;294(3):660-8.
Expert Panel on MR Safety, Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG
Jr, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson
Imaging. 2013;37(3):501-30.
Gani I, Litchfield I, Shukla D, Delanerolle G, Cockburn N, Pathmanathan A.
Understanding “Alert Fatigue” in Primary Care: Qualitative Systematic Review
of General Practitioners Attitudes and Experiences of Clinical Alerts, Prompts,
and Reminders. J Med Internet Res. 2025;27:e62763.
Han JM, Heo KN, Kim AJ, Lee AY, Min S, Ah YM, et al. Medication-related incidents
in acute care hospitals among different age groups: an analysis of national
patient safety report data. Pharmacoepidemiol Drug Saf. 2024;33(6):e5819.
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical
safety checklist to reduce morbidity and mortality in a global population. N
179

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### PDF p.200

의원급 의료기관의 환자안전사고 예방 및 대처를 위한 방안
Engl J Med. 2009;360(5):491-9.
Hollnagel E. Safety-I and Safety-II: the past and future of safety management.
Farnham: Ashgate (CRC Press); 2014.
Hollnagel E. Safety-II in practice: developing the resilience potentials. Abingdon:
Routledge; 2018.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health
Res. 2005;15(9):1277-88.
Institute for Safe Medication Practices. ISMP list of confused drug names [Internet].
Plymouth Meeting (PA): ISMP; 2023 [cited 2025 Dec 1]. Available from:
https://www.ismp.org/recommendations/confused-drug-names
Institute for Safe Medication Practices. ISMP list of high-alert medications in
community/ambulatory care settings [Internet]. Plymouth Meeting (PA): ISMP;
2021 [cited 2025 Dec 1]. Available from: https://www.ismp.org/
recommendations/high-alert-medications-community-ambulatory-list
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st
century. Washington (DC): National Academies Press; 2001.
Jang GC, Chang YS, Choi SH, Song WJ, Lee SY, Park HS, et al. Overview of
anaphylaxis in Korea: diagnosis and management. Allergy Asthma Respir Dis.
2013;1(3):181-96.
Kim DS, Je NK, Park J, Lee S. Effect of nationwide concurrent drug utilization review
program on drug-drug interactions and related health outcome. Int J Qual
Health Care. 2021;33(3):mzab118.
Kim HB, Kim DK. Clinical features and treatment patterns of radiocontrast
mediainduced anaphylaxis in the emergency department. J Korean Soc Emerg
Med. 2009;20(6):709-14.
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer
health system. Washington (DC): National Academies Press; 2000.
Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, Cheever LW, et al.
Updated US Public Health Service guidelines for the management of
occupational exposures to human immunodeficiency virus and recommendations
for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9):
180

<a id="page-201"></a>

### PDF p.201

참고문헌
875-92.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; Hospital Infection Control
Practices Advisory Committee. Guideline for prevention of surgical site
infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-78.
Miller GA. The magical number seven, plus or minus two: some limits on our capacity
for processing information. Psychol Rev. 1956;63(2):81-97.
Montero-Odasso M, van der Velde N, Martin FC, Kamkar N, et al. World guidelines
for falls prevention and management for older adults: a global initiative. Age
Ageing. 2022;51(9):afac205.
Neal JM, Barrington MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, Rubin
DS, Weinberg G. The third American Society of Regional Anesthesia and Pain
Medicine practice advisory on local anesthetic systemic toxicity: executive
summary 2017. Reg Anesth Pain Med. 2018;43(2):113-23.
Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain
Medicine local anesthetic systemic toxicity checklist: 2020 version. Reg Anesth
Pain Med. 2021;46(1):81-2.
NHS England. Patient Safety Incident Response Framework (PSIRF). London: NHS
England; 2022. Available from: https://www.england.nhs.uk/long-
read/patient-safety-incident-response-framework/
NHS England. Primary care patient safety strategy. London: NHS England; 2024.
Available from: https://www.england.nhs.uk/long-read/primary-
care-patient-safety-strategy/
Nolan JP, Maconochie IK, Soar J, Olasveengen TM, Greif R, Wyckoff MH, et al.
Executive summary: 2020 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment
Recommendations. Circulation. 2020;142(16 Suppl 1):S2-27.
O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al.
Guidelines for the prevention of intravascular catheter-related infections.
MMWR Recomm Rep. 2002;51(10):1-26.
Ock M, Jeong H, Kim JH, Yum H, Lee JH, Jo MW. Physicians’ awareness and
experiences of patient safety from 2021 to 2023 in Korea: a cross-sectional
181

<a id="page-202"></a>

### PDF p.202

의원급 의료기관의 환자안전사고 예방 및 대처를 위한 방안
survey study. J Korean Med Assoc. 2025;68(4):253-65.
Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for
falls in hospital in-patients: a systematic review. Age Ageing.
2004;33(2):122-30.
Oprea AD, Ostapenko LJ, Sweitzer BJ, Selzer A, Irizarry-Alvarado JM, Hurtado
Andrade MD, et al. Perioperative management of patients taking glucagon-like
peptide 1 receptor agonists: Society for Perioperative Assessment and Quality
Improvement (SPAQI) multidisciplinary consensus statement. Br J Anaesth.
2025;135(1):48-78.
Panesar SS, deSilva D, Carson-Stevens A, Cresswell KM, Salvilla SA, Slight SP, et al.
How safe is primary care? A systematic review. BMJ Qual Saf.
2016;25(7):544-53.
Pennsylvania Patient Safety Authority. Safety in the MR environment: ferromagnetic
projectile objects in the MRI scanner room. Harrisburg (PA): Pennsylvania Patient
Safety Authority; 2009. Available from: http://resource.nlm.nih.gov/101563474
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
Reason J. Human error. Cambridge: Cambridge University Press; 1990.
Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate; 1997.
Roberts KH. Some characteristics of one type of high reliability organization. Organ
Sci. 1990;1(2):160-76.
Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for
prevention. Age Ageing. 2006;35(Suppl 2):ii37-41.
Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee.
Guideline for disinfection and sterilization in healthcare facilities, 2008.
Atlanta (GA): CDC; 2019 (update).
Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, et al. Prevention of
hepatitis B virus infection in the United States: recommendations of the Advisory
Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(1):1-31.
Sehulster L, Chinn RY; Centers for Disease Control and Prevention; Healthcare
Infection Control Practices Advisory Committee. Guidelines for environmental
infection control in health-care facilities. Recommendations of CDC and the
182

<a id="page-203"></a>

### PDF p.203

참고문헌
Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR
Recomm Rep. 2003;52(10):1-42.
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices
Advisory Committee. 2007 guideline for isolation precautions: preventing
transmission of infectious agents in healthcare settings. Am J Infect Control.
2007;35(10 Suppl 2):S65-164.
Singh H, Graber ML, Kissam SM, Sorensen AV, Lenfestey NF, Tant EM, et al.
System-related interventions to reduce diagnostic errors: a narrative review.
BMJ Qual Saf. 2012;21(2):160-70.
Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European
Resuscitation Council guidelines 2021: adult advanced life support.
Resuscitation. 2021;161:115-51.
Starfield B. Is primary care essential? Lancet. 1994;344(8930):1129-33.
Stephens M. Patient safety in primary care: a qualitative study of healthcare
professionals’ perspectives. Prim Health Care Res Dev. 2022;23:e14.
Sweller J. Cognitive load during problem solving: effects on learning. Cogn Sci.
1988;12(2):257-85.
Tanner MR, O’Shea JG, Byrd KM, Johnston M, Dumitru GG, Le JN, Lale A, Byrd KK,
Cholli P, Kamitani E, Zhu W, Hoover KW, Kourtis AP. Antiretroviral
postexposure prophylaxis after sexual, injection drug use, or other
nonoccupational exposure to HIV - CDC recommendations, United States,
2025. MMWR Recomm Rep. 2025;74(1):1-56.
The Joint Commission. National Patient Safety Goals® Effective January 2025 for the
Hospital Program. Oakbrook Terrace, IL: The Joint Commission; 2024.
Available from:
https://www.jointcommission.org/standards/national-patient-safety-goals/
Thomas O, Glidewell L, Alderson S, Raynor DK, Wood S. Widespread inappropriate
prescribing for older people with reduced kidney function: what are the harms
and how do we tackle them? A scoping review for primary care. BMJ Qual
Saf. 2025:bmjqs-2025-018736. doi: 10.1136/bmjqs-2025-018736.
U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management
183

<a id="page-204"></a>

### PDF p.204

의원급 의료기관의 환자안전사고 예방 및 대처를 위한 방안
of occupational exposures to HBV, HCV, and HIV and recommendations for
postexposure prophylaxis. MMWR Recomm Rep. 2001;50(11):1-52.
Ushakumari DS, Sladen RN. ASA consensus-based guidance on preoperative
management of patients on glucagon-like peptide-1 receptor agonists.
Anesthesiology. 2024;140(2):346-8.
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in
clinical medicine. BMJ. 1998;316(7138):1154-7.
Vincent CA. Analysis of clinical incidents: a window on the system not a search for
root causes. Qual Saf Health Care. 2004;13(4):242-3.
Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age
of uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2007.
Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs.
2005;52(5):546-53.
Working Group of Resuscitation Council UK. Emergency treatment of anaphylaxis:
guidelines for healthcare providers. London: Resuscitation Council UK; 2021.
World Health Organization. Global patient safety action plan 2021–2030: towards
eliminating avoidable harm in health care. Geneva: WHO; 2021.
World Health Organization. Patient safety [Internet]. Geneva: WHO; 2023 [cited 2025
Dec 1]. Available from:
https://www.who.int/news-room/fact-sheets/detail/patient-safety
World Health Organization. Temperature sensitivity of vaccines. Geneva: WHO; 2006
(WHO/IVB/06.10).
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs
help too. BMJ. 2000;320(7237):726-7.
Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive load theory: implications
for medical education: AMEE Guide No. 86. Med Teach. 2014;36(5):371-84.
Yun YH, Chung YK, Jeong JS, Jeong IS, Park ES, Yoon SW, et al. Epidemiological
characteristics and scale for needlestick injury in some university hospital
workers. Korean J Occup Environ Med. 2011;23(4):371-82.
184

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의원급 의료기관의 환자안전사고
예방 및 대처를 위한 방안
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