شناسایی و تجزیه و تحلیل خطاهای انسانی در بخش مراقبت‌های ویژه قلب بیمارستان نفت تهران
محورهای موضوعی :
مدیریت محیط زیست
محسن شنوفی
1
,
سید ابوالفضل ذاکریان
2
,
هانیه نیکومرام
3
,
مریم موفق
4
1 - کارشناس ارشد، گروه مدیریت محیط‌زیست (HSE)، دانشکده محیط‌زیست و انرژی، دانشگاه آزاد اسلامی، واحد علوم و تحقیقات، تهران، ایران.
2 - دانشیار، گروه بهداشت حرفه‌ای، دانشکده بهداشت و انستیتو تحقیقات بهداشتی، دانشگاه علوم پزشکی تهران، تهران، ایران.
3 - استادیار، گروه مدیریت محیط‌زیست (HSE)، دانشکده محیط‌زیست و انرژی، دانشگاه آزاد اسلامی، واحد علوم و تحقیقات، تهران، ایران. *(مسوول مکاتبات)
4 - کارشناس ارشد، گروه مهندسی بهداشت حرفه‌ای، دانشکده بهداشت، دانشگاه علوم پزشکی همدان، همدان، ایران.
تاریخ دریافت : 1396/03/29
تاریخ پذیرش : 1396/05/04
تاریخ انتشار : 1398/02/01
کلید واژه:
ریسک,
خطای انسانی,
بهداشت و درمان,
مراقبت‌های ویژه قلب,
چکیده مقاله :
زمینه و هدف: علّت اکثر حوادث بزرگ دنیا خطای انسانی شناخته شده است. از این رو جهت کاهش خطاهای انسانی در ارزیابی و مدیریت ریسک نیاز جداگانه ای به ارزیابی ریسک ناشی از خطای انسانی وجود دارد که این نیاز می تواند با استفاده از آنالیز قابلیت اطمینان انسانی تامین گردد. در صنعت بهداشت و درمان، هر ساله بیماران زیادی توسط خطاهای پزشکی جان خود را از دست می دهند. خطاهای درمانی مشکلی جهانی است و اخیرا به موضوعی چالش برانگیز در بخش های مختلف درمانی تبدیل شده است. روش بررسی: این مطالعه از نوع تحلیلی- توصیفی است که در آن به منظور تجزیه و تحلیل خطاهای انسانی در بخش مراقبت های ویژه قلب بیمارستان نفت تهران از روش SHERPA استفاده شده است. یافته ها: در مجموع، در بخش مراقبت های ویژه قلب، تعداد 450 خطا شناسایی شد که 242 خطا (%54) مربوط به فعالیت های پرستاری، 43 خطا (9 %) مربوط به پزشک عمومی و 165 خطا (%37) مربوط به پزشک متخصص می باشند. همچنین با توجه به نتایج تجزیه و تحلیل ریسک انجام شده، 45/12% خطاها با ریسک غیر قابل قبول، 30/22% خطاها با ریسک نامطلوب، 11/43% خطاها با ریسک قابل قبول ولی نیاز به تجدید نظر و22/14% خطاها با ریسک قابل قبول بدون نیاز به تجدید نظر می باشند. بحث و نتیجه گیری: در نهایت می توان این نتیجه را استنباط نمود که روش SHERPA در صنعت بهداشت و درمان قابل اجرا بوده و در شناسایی و تجزیه و تحلیل خطاهای انسانی، بسیار موثر می باشد.
چکیده انگلیسی:
Background and Objective: Human error has been identified as a main cause of most of the major accidents in the world. In order to reduce human errors in the risk assessment and management, it is necessary to assess the risks resulting from human errors which can be guaranteed by conducting human reliability analysis. In the healthcare industry, each year many patients are losing their lives because of clinical errors. Clinical errors, as a global problem, have recently been turned into a challenging issue in various healthcare sector cares. Method: Thissurvey is an analytical-descriptive study, where SHERPA method was used for analyzing human errors in CCU unit of Tehran's Naft hospital. Findings: In total, 450 errors were identified in CCU unit, from which 242 errors (45%) were related to nursing actions, 43 errors (9%) belonged to general practitioners, and 165 errors (37%) were for medical specialists. Also, according to the results of the risk analysis, 12.45% of errors were unacceptable, 30.22% had undesirable risk level, 43.11% were identified with acceptable risk level requiring revision, and 14.22% had acceptable risk level without a need for revision. Discussion and Conclusion: In the end, it can be concluded that SHERPA method is an appropriate method to be used in the healthcare industry as it is very effective in identifying and analyzing human errors.
منابع و مأخذ:
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients - Results of the Harvard Medical Practice Study I. Qual Saf Health Care. 2004; 13(2):145-51.
Reason J. Human error: models and management. BMJ. 2000:320:768.
ZarraNezhad A, Jabbari M, Keshavarzi M. Identification of the Human Errors in Control Room Operators by Application of HEIST Method (Case Study in Oil Company). ioh. 2013; 10 (2) :11-23, (In Persian).
Maddah S, Ghasemi, M. Application of Fuzzy Logic in the CREAM Method to Evaluate Human Errors in the control of a Petrochemical Industry. 7th National Conference on Occupational Health. 2011, (In Persian)
Santamaria Ramiro J, Brana P. Risk analysis and reduction in the chemical process industry. New York: Blackie Academic & Professional. 1998
Fontan, J.E, Maneglier V, Nguyen V.X, Brion F, Loirat C. “Medication Errors in Hospitals: Computerized Unit Dose Drug Dispensing System Versus Ward Stock Distribution System,” Pharmacy World Science journal, 2003; 25(3): 112–17.
Verbano C, Turra F. A human factors and reliability approach to clinical risk management: Evidence from Italian cases. Safety science. 2010;48(5):625-39.
Oszvald Á, Vatter H, Byhahn C, Seifert V, Güresir E. “Team time-out” and surgical safety experiences in 12,390 neurosurgical patients. Neurosurg Focus. 2012;33(5): E6.
Anoosheh M, Ahmadi F, Faghihzadeh S, Vaismoradi M. Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran. International Council of Nurses. 2008.
Mazlomi A, Hamzeiyan Ziarane M, Dadkhah A, Jahangiri M, Maghsodipour M, Mohadesy P et al. Assessment of Human Errors in an Industrial Petrochemical Control Room using the CREAM Method with a Cognitive Ergonomics Approach. sjsph. 2011; 8 (4) :15-30, (In Persian).
Küng K, Carrel T, Wittwer B, Engberg S, Zimmermann N, Schwendimann R. Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method. Nursing Research and Practice. 2013.
Johnstone M-J. Patient safety ethics and human error management in ED contexts Part I: Development of the global patient safety movement. Australasian Emergency Nursing Journal. 2007;10(1):13-20.
Mansour M, James V, Edgley A. Investigating the safety of medication administration in adult critical care settings. Nurs Crit Care. 2012 17(4):189-197.
Wilcock M, Harding G, Moore L, Nicholls I, Powell N, Stratton J. What do hospital staff in the UK think are the causes of penicillin medication errors? Int J Clin Pharm. 2013;35(1):72-78.
Mohammadfam I, Movafagh M, Soltanian A, Salavati M, Bashirian S. Assessment of human errors in the intensive cardiac care unit nursing profession using the SPAR-H. tkj. 2015; 7 (1) :10-22, (In Persian).
Stanton N, Salmon P, Baber C. Human factors design & evaluation methods review Human error identification techniques “SHERPA” 1ed, Alvington 2004; 140-8
Salmon P, Stanton N, Walker G. Human Factors Design Methods Review Authors [Online]. 2003 [cited 2003 Nov 28]; Available from:URL:http://www.hfidtc.com/research/methods/methods-reports/phase-1/hf-designmethods- review.pdf
Dastaran S, Hasheinejhad N, Shahravan A, Baneshi M, Faghihi A. Identification and Assessment of Human Errors in Postgraduate Endodontic Students of Kerman University of Medical Sciences by Using the SHERPA Method. johe. 2016; 2 (4) :44-51, (In Persian).
Kirwan, B., S. Scannali, and L. Robinson, Acase study of a human reliability assessment for an existing nuclear power plant. Applied Ergonomics, 1996. 27(5): p. 289-302.
Kirwan, B., Human error identification techniques for risk assessment of high risk systems - Part 2: Towards a framework approach. Applied Ergonomics, 1998. 29(5): p. 299-318. Atkins (2003) Human factors Briefing notes 12.
7. IOE, A.R., Rail-Specific HRA Tool for Driving Tasks (T270). 2004, RSSB Research Report: London.
Annett, J. and N. Stanton, Task analysis. 2000, London; New York: Taylor & Francis. 242 p.
Mirzaei aliabadi M, Mohammad fam I, Karimi S. Identification and assessment of human errors in blasting operations in Iron Ore Mine using SHERA technique. johe. 2015; 2 (1) :57-65, (In Persian).
Mahdavi S, Heydari Farsani A, Tajvar A. Identification and Assessment of Human Error Due to design in damagingto the Sour Water Equipment and SRP Unit of Control Room in A Refinery Plant using SHERPA Technique. JHSW. 2013; 2 (4) :61-70, (In Persian).
Embrey D. Qualitative and quantitative evaluation of human error in risk assessment. Human factors for engineers. Landon: IET. 2004; 151.
Habibi A, Gharib S, Mohamadfam A, Rismanchian. Evaluation & Management of Human Error in the Operators of Isfahan Oil Refinery control room by the use of SHERPA Method. Health system researches. 2011; 7 (4), (In Persian).
Ghasemi M, Nasl saraji G, Zakerian A, Azhdari M. Ergonomic assessment (identification, prediction and control) of human error in a control room of the petrochemical industry using the SHERPA Method. sjsph. 2010; 8 (1) :41-52, (In Persian).
Ghasemi A, Atabi F, Golbabaei F. Human Error Classification for the Permit to Work System by SHERPA in a Petrochemical Industry. johe. 2015; 2 (3) :66-73, (In Persian).
JC B. Recurring Causes of Recent Chemical Accidents. San Antonio. 1998.19
Petersen D. Human error Reduction and safety management. 1982; 3.
Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995; 23(2):29.
Mohammadfam I, Saeidi C. Evaluating human errors in cataract surgery using the SHERPA technique. J Ergon. 2015; 2 (4) :41-47, (In Persian).
Mazloumi A, Kermani A, NaslSeraji J, GhasemZadeh F. Identification and evaluation of human errors of physicians at emergency ward of an educational hospital in Semnan city using SHERPA technique. tkj. 2013; 5 (3) :67-78, (In Persian).
Ferner R, Aronson J. Preventability of drug-related harms. Part 1: a systematic review. Drug Saf. 2010; 33(11): 985-994
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Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients - Results of the Harvard Medical Practice Study I. Qual Saf Health Care. 2004; 13(2):145-51.
Reason J. Human error: models and management. BMJ. 2000:320:768.
ZarraNezhad A, Jabbari M, Keshavarzi M. Identification of the Human Errors in Control Room Operators by Application of HEIST Method (Case Study in Oil Company). ioh. 2013; 10 (2) :11-23, (In Persian).
Maddah S, Ghasemi, M. Application of Fuzzy Logic in the CREAM Method to Evaluate Human Errors in the control of a Petrochemical Industry. 7th National Conference on Occupational Health. 2011, (In Persian)
Santamaria Ramiro J, Brana P. Risk analysis and reduction in the chemical process industry. New York: Blackie Academic & Professional. 1998
Fontan, J.E, Maneglier V, Nguyen V.X, Brion F, Loirat C. “Medication Errors in Hospitals: Computerized Unit Dose Drug Dispensing System Versus Ward Stock Distribution System,” Pharmacy World Science journal, 2003; 25(3): 112–17.
Verbano C, Turra F. A human factors and reliability approach to clinical risk management: Evidence from Italian cases. Safety science. 2010;48(5):625-39.
Oszvald Á, Vatter H, Byhahn C, Seifert V, Güresir E. “Team time-out” and surgical safety experiences in 12,390 neurosurgical patients. Neurosurg Focus. 2012;33(5): E6.
Anoosheh M, Ahmadi F, Faghihzadeh S, Vaismoradi M. Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran. International Council of Nurses. 2008.
Mazlomi A, Hamzeiyan Ziarane M, Dadkhah A, Jahangiri M, Maghsodipour M, Mohadesy P et al. Assessment of Human Errors in an Industrial Petrochemical Control Room using the CREAM Method with a Cognitive Ergonomics Approach. sjsph. 2011; 8 (4) :15-30, (In Persian).
Küng K, Carrel T, Wittwer B, Engberg S, Zimmermann N, Schwendimann R. Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method. Nursing Research and Practice. 2013.
Johnstone M-J. Patient safety ethics and human error management in ED contexts Part I: Development of the global patient safety movement. Australasian Emergency Nursing Journal. 2007;10(1):13-20.
Mansour M, James V, Edgley A. Investigating the safety of medication administration in adult critical care settings. Nurs Crit Care. 2012 17(4):189-197.
Wilcock M, Harding G, Moore L, Nicholls I, Powell N, Stratton J. What do hospital staff in the UK think are the causes of penicillin medication errors? Int J Clin Pharm. 2013;35(1):72-78.
Mohammadfam I, Movafagh M, Soltanian A, Salavati M, Bashirian S. Assessment of human errors in the intensive cardiac care unit nursing profession using the SPAR-H. tkj. 2015; 7 (1) :10-22, (In Persian).
Stanton N, Salmon P, Baber C. Human factors design & evaluation methods review Human error identification techniques “SHERPA” 1ed, Alvington 2004; 140-8
Salmon P, Stanton N, Walker G. Human Factors Design Methods Review Authors [Online]. 2003 [cited 2003 Nov 28]; Available from:URL:http://www.hfidtc.com/research/methods/methods-reports/phase-1/hf-designmethods- review.pdf
Dastaran S, Hasheinejhad N, Shahravan A, Baneshi M, Faghihi A. Identification and Assessment of Human Errors in Postgraduate Endodontic Students of Kerman University of Medical Sciences by Using the SHERPA Method. johe. 2016; 2 (4) :44-51, (In Persian).
Kirwan, B., S. Scannali, and L. Robinson, Acase study of a human reliability assessment for an existing nuclear power plant. Applied Ergonomics, 1996. 27(5): p. 289-302.
Kirwan, B., Human error identification techniques for risk assessment of high risk systems - Part 2: Towards a framework approach. Applied Ergonomics, 1998. 29(5): p. 299-318. Atkins (2003) Human factors Briefing notes 12.
7. IOE, A.R., Rail-Specific HRA Tool for Driving Tasks (T270). 2004, RSSB Research Report: London.
Annett, J. and N. Stanton, Task analysis. 2000, London; New York: Taylor & Francis. 242 p.
Mirzaei aliabadi M, Mohammad fam I, Karimi S. Identification and assessment of human errors in blasting operations in Iron Ore Mine using SHERA technique. johe. 2015; 2 (1) :57-65, (In Persian).
Mahdavi S, Heydari Farsani A, Tajvar A. Identification and Assessment of Human Error Due to design in damagingto the Sour Water Equipment and SRP Unit of Control Room in A Refinery Plant using SHERPA Technique. JHSW. 2013; 2 (4) :61-70, (In Persian).
Embrey D. Qualitative and quantitative evaluation of human error in risk assessment. Human factors for engineers. Landon: IET. 2004; 151.
Habibi A, Gharib S, Mohamadfam A, Rismanchian. Evaluation & Management of Human Error in the Operators of Isfahan Oil Refinery control room by the use of SHERPA Method. Health system researches. 2011; 7 (4), (In Persian).
Ghasemi M, Nasl saraji G, Zakerian A, Azhdari M. Ergonomic assessment (identification, prediction and control) of human error in a control room of the petrochemical industry using the SHERPA Method. sjsph. 2010; 8 (1) :41-52, (In Persian).
Ghasemi A, Atabi F, Golbabaei F. Human Error Classification for the Permit to Work System by SHERPA in a Petrochemical Industry. johe. 2015; 2 (3) :66-73, (In Persian).
JC B. Recurring Causes of Recent Chemical Accidents. San Antonio. 1998.19
Petersen D. Human error Reduction and safety management. 1982; 3.
Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M Sprung CL, et al. A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995; 23(2):29.
Mohammadfam I, Saeidi C. Evaluating human errors in cataract surgery using the SHERPA technique. J Ergon. 2015; 2 (4) :41-47, (In Persian).
Mazloumi A, Kermani A, NaslSeraji J, GhasemZadeh F. Identification and evaluation of human errors of physicians at emergency ward of an educational hospital in Semnan city using SHERPA technique. tkj. 2013; 5 (3) :67-78, (In Persian).
Ferner R, Aronson J. Preventability of drug-related harms. Part 1: a systematic review. Drug Saf. 2010; 33(11): 985-994
