1Graduate Student, Department of Nursing, Inha University, Incheon, Korea
2Associate Professor, Department of Nursing, Gangneung-Wonju National University, Wonju, Korea
Copyright © 2022 Korean Academy of Child Health Nursing.
This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Authors' contribution
Conceptualization: all authors; Data curation, Formal analysis: all authors; Writing-original draft, Writing-review and editing: all authors; Final approval of published version: all authors.
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Characteristics | Categories | n (%) |
---|---|---|
Year of incidents | 2000-2004 | 2 (16.6) |
2005-2009 | 7 (58.5) | |
2010-2014 | 1 (8.3) | |
2015-2019 | 2 (16.6) | |
Defendants | Nurse | 6 (50.0) |
Nurse and doctor | 6 (50.0) | |
Guilty | Involuntary manslaughter | 7 (58.3) |
At-fault injury | 5 (41.7) | |
Victim's age (year) | Newborn | 7 (58.3) |
0.5-1 | 1 (8.3) | |
2-5 | 3 (25.1) | |
6-13 | 1 (8.3) | |
Judgments | Innocent | 1 (8.3) |
Fine* | 8 (66.7) | |
Suspended sentence | 1 (8.3) | |
Probation* | 2 (16.7) |
Case number | Type of Austin category* | Charge/Disposition | Brief summary |
Tatbestand for nursing negligence |
Illegality | Liability | Foreseeability (duty to foresee possible results) | Avoidability (duty to avoid possible results) | ||
---|---|---|---|---|---|---|---|---|---|---|
Breach of duty of care | Outcome | Causation | ||||||||
1 | a, c, f | Professional negligence resulting in death/Acquitted | Four premature infants died from sepsis caused by Citrobacter freundii infections in a NICU. | Negligence of not preparing SMOFlipid (lipid injectable emulsion) in an aseptic environment and not following the instruction to use immediately after opening; | Four newborns died of sepsis. | The negligence in the process of SMOF lipid injection preparation caused Citrobacter infections, which resulted in sepsis and death. This accusation was not supported by evidence of causality. | Doctors and nurses must take appropriate and sufficient infection control measures. | Doctors have the duty of care to prevent incidents by providing sufficient guidance and supervision to prevent nurses from committing mistakes while carrying out medical activities. | In dispensing SMOFlipid, its infection risk was foreseeable in newborns with very low birth weight and newborns in critical condition, given their incomplete defense system against microorganisms. | NICU Nursing Management Guidelines [16]: injection preparation time is approximately 30 minutes. |
negligence of not following the work guideline that the one who has prepared the injection agent should administer it; | Medical personnel's duty of care in drug administration is to prevent harmful results to the patient before, during, and after the medication administration (long-term medication). | Enforcement decree of the Medical Service Act, Art. 39-34 [17]: injection in a single-use syringe without delay. | ||||||||
negligence of neglecting and condoning the practice of dispensing and delayed administration; | Nursing basics: Nurses must avoid medication errors by administering only medications prepared by themselves. | |||||||||
negligence of not conducting infection control and education for nurses as the head nurse. | ||||||||||
2 | d | Professional negligence resulting in injury/Fine 5,000,000 won (4,100 USD) | In the neonatal room, the infant was dropped on the floor from a height of 1 meter, resulting in parietal fractures. | Breach of the professional duty of care to avoid dropping the victim. | Newborn's unclear parietal bone fracture. | Factual causation was established. | Illegality was applicable due to neglecting the professional duty of care. | Newborns are vulnerable to shock, and they are fully entrusted to the nurse. | Newborns must be moved in a cradle and the fall should have been foreseen. | Duty to take precautions to avoid falls because newborns are a high-risk group and have no control over their bodies. |
3 | a, b, c | Professional negligence resulting in death/6-month jail term with 2 years on probation | A 2-year-old boy died of shock after an antibiotic injection was administered without paying attention to the fact that he had tested positive for the antibiotic skin reaction test. | Injection of antibiotics despite the confirmed antibiotics resistance and the instruction not to administer it, and breach of duty of care to properly treat the anaphylactic shock and record the incident. | Death from anaphylactic shock. | Shortness of breath and circulatory collapse immediately after the intravenous injection of antibiotics prescribed at 23:40. | The professional duty of care to administer antibiotics safely. | The professional duty of care is to conduct an antibiotic skin test and confirm no adverse reactions when administering antibiotics to the patient as per the doctor's prescription. | Death could be foreseen when administering antibiotics regardless of the confirmed antibiotic skin reaction. | In the case of a confirmed antibiotic skin reaction, the injection should not be administered and the doctor should be notified. |
4 | g | Professional negligence resulting in injury/Fine 1,500,000 won (1,230 USD) | In the delivery room, a newborn baby was laid on an electric hot pack placed on the cradle, resulting in second-and third-degree burns to the left shoulder blade, trunk, and lower limbs. | Breach of the professional duty of care to prevent an accident by participating in the delivery process after checking all measures for the safety of the newborn. | Deep burns in the left shoulder blade, trunk, and lower limbs from an electric hot pack. | No other possible causes of burns were found. | Violation of the duty of due diligence for safety measures. | In the delivery process, the nurse must take measures for the newborn's safety. | The risk of burns and damage could be foreseen, considering the fragile skin condition of newborns. | Burns could be avoided by keeping the temperature of the hot pack at a low level or by removing it for safe environmental management. |
5 | a, b | Professional negligence resulting in injury/Suspended sentence | In the pediatric ward, a 6-month-old infant suffered an amputation injury to the fifth finger of the right hand while removing the bandage with an intravenous fluid needle on the back of the hand. | Breach of the professional duty of care to ensure safe management of all measures related to medication administration. | Amputation injury to the fifth finger of the right hand. | The cut was made with the nurse's scissors. | Negligence for noncompliance with all medication-relat ed matters despite the need for safe management. | Obligation to ensure safe management for accurate medication administration taking into account possible situations of highly vulnerable patients. | It could be confirmed that the child could not stay still, and it could be foreseen that cutting the band-aid with scissors could cause injury. | This safety accident could be avoided by using safe scissors to remove the band-aid or by modifying the method of fixing the injection site. |
6 | c, d | Professional negligence resulting in injury/6-month jail term with 2 years on probation | A 16-month-old girl hospitalized for high fever in the waiting ward vomited antipyretic syrup and powdered milk, and showed cyanosis, tachycardia, and convulsions. She was left untreated to maintain breathing, and the report to the doctor was also delayed, resulting in grade 1 encephalopathy. | Breach of professional duty of care to take emergency measures to maintain the airway in case of cyanosis due to hypoxia, low oxygen saturation and heart rate, and difficulty with spontaneous breathing. | Grade 1 encephalopat hy. | Causation was established by the fact that change in consciousness occurred immediately after the cyanosis and tachycardia. | Negligence of noncompliance with emergency care in a situation requiring it. | Obligation to immediately report to the doctor upon confirming the patient's condition that required immediate airway maintenance. | Respiratory failure is a foreseeable result of decreased oxygen saturation and tachycardia as per the professional knowledge of the nurse. | When hypoxia occurred, the nurse should have secured the airway and provided oxygen using ventilation and airway maintenance devices. |
Negligence in failure to immediately notify the physician of the victim's symptoms and perform airway maintenance. | Negligence of delaying the time for airway maintenance by failing to notify of symptoms immediately. | Actions that require checking the condition of the emergency patient and performing emergency measures such as immediate airway maintenance and artificial respiration. | ||||||||
7 | b | Professional negligence resulting in death/Fine 3,000,000 won (2,500 USD) | The newborn died of suffocation due to the inability to respond immediately to situations such as vomiting after feedings in the neonatal room. | Breach of professional duty of care to guide and supervise nurses and provide human and material resources to prevent suffocation accidents while feeding. | Death (estimated) from airway obstruction and asphyxiation by vomit. | No record in the precedent. | Negligence of not providing human and material resources necessary for the proper care of newborns. | Liability for guiding and supervising nurses in addition to providing human and material resources. | The hospital director should have foreseen that it is difficult to safely manage 18 newborns with one nurse. | The incident could have been avoided with proper guidance and supervision of nurses in addition to the provision of human and material resource. |
Neglecting the duty by allocating at least two nurses on the night shift to take care of 18 newborns. | ||||||||||
8 | b | Professional negligence resulting in death/Fine 3,000,000 won (2,500 USD) | The newborn died of suffocation because the nurse could not immediately respond to situations such as vomiting after shortening the feeding interval in the neonatal room of the postpartum care center. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feeding (holding them in the arms) and burping them and laying them down appropriately. | Death from suffocation due to short feeding intervals and failure to respond in a timely way to vomiting after feeding. | Proven causation of asphyxiation from lactation and vomiting. | Breach of duty of care to prevent incidents of feeding-related suffocation of newborns. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feedings (holding them in the arms, burping them, and laying them down appropriately). | Nurses can foresee that when several newborns are fed concurrently or fed in a position other than held in the arms, newborns are likely to vomit, which can lead to suffocation. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feeding (holding them in the arms, burping them, and laying them down appropriately). |
9† | a, d | Professional negligence resulting in death/Fine 5,000,000 won (4,100 USD) | A 13-year-old boy admitted to the emergency room for fulminant hepatitis was not treated properly and his symptoms of loss of consciousness and shortness of breath were not immediately reported to the doctor. Moreover, no follow-up observation was made after administering valium. The patient was transferred to a tertiary hospital, where he died. | Breach of duty of care to closely monitor the progress of patients with unconfirmed diagnoses accompanied by abnormal blood test results and failure to report problems immediately. | Death by respiratory failure. | Although the outcome was possible, the nurse did not foresee it or take measures to avoid it. | Breach of duty of care to closely monitor the progress of patients with unconfirmed diagnoses accompanied by abnormal blood test results and failure to report problems immediately. | The act of closely observing the emergency patient's condition and promptly reporting any changes so that the patient receives timely and appropriate treatment. | A nurse equipped with professional knowledge must be able to foresee that decreased oxygen saturation and tachycardia would lead to respiratory failure. | A nurse equipped with professional knowledge knows that in the case of abnormal blood test results and low oxygen saturation, the condition can be prevented from worsening by immediately opening the airway and providing mechanical ventilation such as oxygen administration. |
Negligence by not closely observing for side effects after administration of a high-risk medication that could lead to respiratory failure. | ||||||||||
10 | a, c, d | Professional negligence resulting in death/Fine of 7,000,000 won (5,750 USD) | A 14-month-old girl who had respiratory distress symptoms due to pneumonia and asthma died due to a failure to conduct proper testing and administer a timely therapy such as mechanical ventilation, even though inhalation therapy and drug treatment with epinephrine/aminophyllin e were found ineffective. | Apart from the doctor's inappropriate treatment approaches, the nurse was also prosecuted and convicted for a breach of duty of care for not observing and reporting on the patient with respiratory distress. | Death due to failure to provide timely and proper treatment. | In a situation in which inhalation therapy and drug treatment with epinephrine/ aminophylline were found ineffective, the nurse failed to secure the airway by other means, which led to death of the patient. | Negligence in delaying the time for airway maintenance by not notifying of symptoms immediately. | Obligation to immediately report to the doctor upon confirming the patient has a condition that requires immediate airway maintenance. | Respiratory failure is a foreseeable result of decreased oxygen saturation and tachycardia as per the nurse's professional knowledge. | When hypoxia occurred, the nurse should have secured the airway and provided oxygen using ventilation and airway maintenance devices. |
Characteristics | Categories | n (%) |
---|---|---|
Year of incidents | 2000-2004 | 2 (16.6) |
2005-2009 | 7 (58.5) | |
2010-2014 | 1 (8.3) | |
2015-2019 | 2 (16.6) | |
Defendants | Nurse | 6 (50.0) |
Nurse and doctor | 6 (50.0) | |
Guilty | Involuntary manslaughter | 7 (58.3) |
At-fault injury | 5 (41.7) | |
Victim's age (year) | Newborn | 7 (58.3) |
0.5-1 | 1 (8.3) | |
2-5 | 3 (25.1) | |
6-13 | 1 (8.3) | |
Judgments | Innocent | 1 (8.3) |
Fine |
8 (66.7) | |
Suspended sentence | 1 (8.3) | |
Probation |
2 (16.7) |
Case number | Type of Austin category |
Charge/Disposition | Brief summary | Tatbestand for nursing negligence |
Illegality | Liability | Foreseeability (duty to foresee possible results) | Avoidability (duty to avoid possible results) | ||
---|---|---|---|---|---|---|---|---|---|---|
Breach of duty of care | Outcome | Causation | ||||||||
1 | a, c, f | Professional negligence resulting in death/Acquitted | Four premature infants died from sepsis caused by Citrobacter freundii infections in a NICU. | Negligence of not preparing SMOFlipid (lipid injectable emulsion) in an aseptic environment and not following the instruction to use immediately after opening; | Four newborns died of sepsis. | The negligence in the process of SMOF lipid injection preparation caused Citrobacter infections, which resulted in sepsis and death. This accusation was not supported by evidence of causality. | Doctors and nurses must take appropriate and sufficient infection control measures. | Doctors have the duty of care to prevent incidents by providing sufficient guidance and supervision to prevent nurses from committing mistakes while carrying out medical activities. | In dispensing SMOFlipid, its infection risk was foreseeable in newborns with very low birth weight and newborns in critical condition, given their incomplete defense system against microorganisms. | NICU Nursing Management Guidelines [16]: injection preparation time is approximately 30 minutes. |
negligence of not following the work guideline that the one who has prepared the injection agent should administer it; | Medical personnel's duty of care in drug administration is to prevent harmful results to the patient before, during, and after the medication administration (long-term medication). | Enforcement decree of the Medical Service Act, Art. 39-34 [17]: injection in a single-use syringe without delay. | ||||||||
negligence of neglecting and condoning the practice of dispensing and delayed administration; | Nursing basics: Nurses must avoid medication errors by administering only medications prepared by themselves. | |||||||||
negligence of not conducting infection control and education for nurses as the head nurse. | ||||||||||
2 | d | Professional negligence resulting in injury/Fine 5,000,000 won (4,100 USD) | In the neonatal room, the infant was dropped on the floor from a height of 1 meter, resulting in parietal fractures. | Breach of the professional duty of care to avoid dropping the victim. | Newborn's unclear parietal bone fracture. | Factual causation was established. | Illegality was applicable due to neglecting the professional duty of care. | Newborns are vulnerable to shock, and they are fully entrusted to the nurse. | Newborns must be moved in a cradle and the fall should have been foreseen. | Duty to take precautions to avoid falls because newborns are a high-risk group and have no control over their bodies. |
3 | a, b, c | Professional negligence resulting in death/6-month jail term with 2 years on probation | A 2-year-old boy died of shock after an antibiotic injection was administered without paying attention to the fact that he had tested positive for the antibiotic skin reaction test. | Injection of antibiotics despite the confirmed antibiotics resistance and the instruction not to administer it, and breach of duty of care to properly treat the anaphylactic shock and record the incident. | Death from anaphylactic shock. | Shortness of breath and circulatory collapse immediately after the intravenous injection of antibiotics prescribed at 23:40. | The professional duty of care to administer antibiotics safely. | The professional duty of care is to conduct an antibiotic skin test and confirm no adverse reactions when administering antibiotics to the patient as per the doctor's prescription. | Death could be foreseen when administering antibiotics regardless of the confirmed antibiotic skin reaction. | In the case of a confirmed antibiotic skin reaction, the injection should not be administered and the doctor should be notified. |
4 | g | Professional negligence resulting in injury/Fine 1,500,000 won (1,230 USD) | In the delivery room, a newborn baby was laid on an electric hot pack placed on the cradle, resulting in second-and third-degree burns to the left shoulder blade, trunk, and lower limbs. | Breach of the professional duty of care to prevent an accident by participating in the delivery process after checking all measures for the safety of the newborn. | Deep burns in the left shoulder blade, trunk, and lower limbs from an electric hot pack. | No other possible causes of burns were found. | Violation of the duty of due diligence for safety measures. | In the delivery process, the nurse must take measures for the newborn's safety. | The risk of burns and damage could be foreseen, considering the fragile skin condition of newborns. | Burns could be avoided by keeping the temperature of the hot pack at a low level or by removing it for safe environmental management. |
5 | a, b | Professional negligence resulting in injury/Suspended sentence | In the pediatric ward, a 6-month-old infant suffered an amputation injury to the fifth finger of the right hand while removing the bandage with an intravenous fluid needle on the back of the hand. | Breach of the professional duty of care to ensure safe management of all measures related to medication administration. | Amputation injury to the fifth finger of the right hand. | The cut was made with the nurse's scissors. | Negligence for noncompliance with all medication-relat ed matters despite the need for safe management. | Obligation to ensure safe management for accurate medication administration taking into account possible situations of highly vulnerable patients. | It could be confirmed that the child could not stay still, and it could be foreseen that cutting the band-aid with scissors could cause injury. | This safety accident could be avoided by using safe scissors to remove the band-aid or by modifying the method of fixing the injection site. |
6 | c, d | Professional negligence resulting in injury/6-month jail term with 2 years on probation | A 16-month-old girl hospitalized for high fever in the waiting ward vomited antipyretic syrup and powdered milk, and showed cyanosis, tachycardia, and convulsions. She was left untreated to maintain breathing, and the report to the doctor was also delayed, resulting in grade 1 encephalopathy. | Breach of professional duty of care to take emergency measures to maintain the airway in case of cyanosis due to hypoxia, low oxygen saturation and heart rate, and difficulty with spontaneous breathing. | Grade 1 encephalopat hy. | Causation was established by the fact that change in consciousness occurred immediately after the cyanosis and tachycardia. | Negligence of noncompliance with emergency care in a situation requiring it. | Obligation to immediately report to the doctor upon confirming the patient's condition that required immediate airway maintenance. | Respiratory failure is a foreseeable result of decreased oxygen saturation and tachycardia as per the professional knowledge of the nurse. | When hypoxia occurred, the nurse should have secured the airway and provided oxygen using ventilation and airway maintenance devices. |
Negligence in failure to immediately notify the physician of the victim's symptoms and perform airway maintenance. | Negligence of delaying the time for airway maintenance by failing to notify of symptoms immediately. | Actions that require checking the condition of the emergency patient and performing emergency measures such as immediate airway maintenance and artificial respiration. | ||||||||
7 | b | Professional negligence resulting in death/Fine 3,000,000 won (2,500 USD) | The newborn died of suffocation due to the inability to respond immediately to situations such as vomiting after feedings in the neonatal room. | Breach of professional duty of care to guide and supervise nurses and provide human and material resources to prevent suffocation accidents while feeding. | Death (estimated) from airway obstruction and asphyxiation by vomit. | No record in the precedent. | Negligence of not providing human and material resources necessary for the proper care of newborns. | Liability for guiding and supervising nurses in addition to providing human and material resources. | The hospital director should have foreseen that it is difficult to safely manage 18 newborns with one nurse. | The incident could have been avoided with proper guidance and supervision of nurses in addition to the provision of human and material resource. |
Neglecting the duty by allocating at least two nurses on the night shift to take care of 18 newborns. | ||||||||||
8 | b | Professional negligence resulting in death/Fine 3,000,000 won (2,500 USD) | The newborn died of suffocation because the nurse could not immediately respond to situations such as vomiting after shortening the feeding interval in the neonatal room of the postpartum care center. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feeding (holding them in the arms) and burping them and laying them down appropriately. | Death from suffocation due to short feeding intervals and failure to respond in a timely way to vomiting after feeding. | Proven causation of asphyxiation from lactation and vomiting. | Breach of duty of care to prevent incidents of feeding-related suffocation of newborns. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feedings (holding them in the arms, burping them, and laying them down appropriately). | Nurses can foresee that when several newborns are fed concurrently or fed in a position other than held in the arms, newborns are likely to vomit, which can lead to suffocation. | Breach of professional duty of care of neonatal nurses to prevent suffocation accidents by carefully and constantly monitoring the condition of newborns who vomit after feeding (holding them in the arms, burping them, and laying them down appropriately). |
9 |
a, d | Professional negligence resulting in death/Fine 5,000,000 won (4,100 USD) | A 13-year-old boy admitted to the emergency room for fulminant hepatitis was not treated properly and his symptoms of loss of consciousness and shortness of breath were not immediately reported to the doctor. Moreover, no follow-up observation was made after administering valium. The patient was transferred to a tertiary hospital, where he died. | Breach of duty of care to closely monitor the progress of patients with unconfirmed diagnoses accompanied by abnormal blood test results and failure to report problems immediately. | Death by respiratory failure. | Although the outcome was possible, the nurse did not foresee it or take measures to avoid it. | Breach of duty of care to closely monitor the progress of patients with unconfirmed diagnoses accompanied by abnormal blood test results and failure to report problems immediately. | The act of closely observing the emergency patient's condition and promptly reporting any changes so that the patient receives timely and appropriate treatment. | A nurse equipped with professional knowledge must be able to foresee that decreased oxygen saturation and tachycardia would lead to respiratory failure. | A nurse equipped with professional knowledge knows that in the case of abnormal blood test results and low oxygen saturation, the condition can be prevented from worsening by immediately opening the airway and providing mechanical ventilation such as oxygen administration. |
Negligence by not closely observing for side effects after administration of a high-risk medication that could lead to respiratory failure. | ||||||||||
10 | a, c, d | Professional negligence resulting in death/Fine of 7,000,000 won (5,750 USD) | A 14-month-old girl who had respiratory distress symptoms due to pneumonia and asthma died due to a failure to conduct proper testing and administer a timely therapy such as mechanical ventilation, even though inhalation therapy and drug treatment with epinephrine/aminophyllin e were found ineffective. | Apart from the doctor's inappropriate treatment approaches, the nurse was also prosecuted and convicted for a breach of duty of care for not observing and reporting on the patient with respiratory distress. | Death due to failure to provide timely and proper treatment. | In a situation in which inhalation therapy and drug treatment with epinephrine/ aminophylline were found ineffective, the nurse failed to secure the airway by other means, which led to death of the patient. | Negligence in delaying the time for airway maintenance by not notifying of symptoms immediately. | Obligation to immediately report to the doctor upon confirming the patient has a condition that requires immediate airway maintenance. | Respiratory failure is a foreseeable result of decreased oxygen saturation and tachycardia as per the nurse's professional knowledge. | When hypoxia occurred, the nurse should have secured the airway and provided oxygen using ventilation and airway maintenance devices. |
Duplicate: the first trial and the second trial are different.
a: administer medications properly, b: monitor for and report deterioration, c: communicate effectively, d: delegate responsibly, e: document in an accurate and timely manner, f: know and follow facility policies and procedures, g: use equipment properly; Twelve cases were coded and analyzed, but only 10 cases were included in the content analysis because Case 9 included precedents from the first trial, the second trial, and the Supreme Court; NICU, neonatal intensive care unit; USD, United States dollar.