تجزیه و تحلیل لایه‌های حفاظتی خطاهای انسانی پرستاران در بخش مراقبت‌های ویژه قلبی با رویکرد آینده‌نگر
محورهای موضوعی : -مدارک پزشکیمحسن شنوفی 1 , سید ابوالفضل ذاکریان 2 , هانیه نیکومرام 3
1 - دانشجوی کارشناسی ارشد، گروه مدیریت محیط زیست(HSE) ، واحد علوم و تحقیقات، دانشگاه آزاد اسلامی، تهران، ایران
2 - دانشیار، گروه بهداشت حرفه‌ای، دانشکده بهداشت و انستیتو تحقیقات بهداشتی، دانشگاه علوم پزشکی تهران، تهران، ایران
3 - استادیار، گروه مدیریت محیط زیست(HSE) ، واحد علوم و تحقیقات، دانشگاه آزاد اسلامی، تهران، ایران
کلید واژه: خطای انسانی, ارزیابی ریسک, موانع, یمارستان, پیامد,
چکیده مقاله :
مقدمه: تحقیقات متعددی نشان داده است که خطای انسانی عامل اصلی وقوع حوادث شغلی است. تنوع جنبه‌های مختلف کاری، ماهیت شغل و پیچیدگی آن می‌تواند بر عملکرد و رفتار شاغل اثر گذاشته و موجب بروز اعمال ناایمن حین انجام کار گردد. این امر سبب می‌شود که شاغل به صورت خواسته و یا ناخواسته دچار خطا شود که در نتیجه منجر به بروز مخاطرات شغلی و حوادث گردد. روش پژوهش: این مطالعه از نوع تحلیلی - توصیفی است که در آن به منظور شناسایی و تجزیه و تحلیل اقدامات کنترلی خطاهای پرستاران در بخش مراقبت‌های ویژه قلبی بیمارستان نفت تهران از روش تجزیه و تحلیل مانع (BA) استفاده شده است. یافته‌ها: نتایج حاصل از کار برگ‌های BA، تعداد 57 مانع را نشان داد که در 8 گروه موانع اجرایی14%، آئین‌نامه‌ای 18%، اقدامات انسانی 10%، نظارت و همکاری 20%، آموزشی 10%، طبیعی 0%، فیزیکی 10%، طراحی محیطی 18% طبقه‌بندی شدند. هم‌چنین 38 مانع‌شکن و 32 اقدام اصلاحی شناسایی شدند. نتیجه‌گیری: در نهایت می‌توان این نتیجه را استنباط نمود که روش BA در صنعت بهداشت و درمان قابل اجرا بوده و در شناسایی لایه‌های حفاظتی خطاهای انسانی، بسیار مفید و موثر می‌باشد.
Introduction: Numerous studies have shown that human error is the main factor in the occurrence of occupational accidents. Diversity of a job’s different aspects, nature of the job and its complexity, can negatively affect a worker’s performance and behavior, thus leading to unsafe acts in a working environment. This also causes workers to intentionally or unintentionally make errors, which itself can be a reason of occupational accidents. Methods: This study is an analytical- descriptive research, where Barrier Analysis (BA) technique has been applied to identify and analyze the nurses’ human errors in the CCU ward of NIOC Tehran hospital. Results: The results of the BA checklists presented 57 barriers classified in 8 groups: administrative barriers (14%), procedural actions (18%), human actins (10%), supervisory and co-working barriers (20%), training (10%), natural barriers (0%), physical barriers (10%) and environmental design (18%). Also, 38 barrier breakers and 32 corrective actions were identified. Conclusion: It can be concluded that BA technique is an appropriate technique to be used in the healthcare and therapy industry as it is helpful in the identification of human error protection layers.
1- Hunszu L, Sheue-Ling H, Thu-Hua L. Economic assessment of human errors in manufacturing environment, Safety Science, 2009; 47: 170–182.
2- Ghasemi M, Jebraiel S, Zakerian SA. Study of ergonomic (Identification, prediction and control) of Human Error in One of Control Room of the petrochemical plant by SHERPA Technique. J Health School and Health research Institute, 1389; 8(1): 5-412. [Persian]
3- kirwan B. A Guide to Practical Human Reliability Assessment. TYLOR and FRANCIS; 1994: 592.
4- Kariuki, SG, Löwe K. Integrating human factors into process hazard analysis. Reliability Engineering and Safety, 2007; 92(12): 1764-73.
5- Ramin Z. Human Error Assessment in Cement Factory with HRMS Method: University of Tehran; 1996.
6- Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. The Lancet, 1997;349(9048):309-13.
7- Moghadam S, Zakerian SA. Ergonomic inHealth care system- Human factor models. Health and safety at work; 2016: 4. [Persian]
8- Aghdami M, Alhani F. The barriers & presentation of solution for performing tasks specific Tehran's children nursery in children hospital. [Persian]
9- Moshiri Z, Rostamzade M, Amlashi S. The survey of knowledge and procced nursing students in their professional duties in Uromia Medical Science University. Congress of Coordination of Education. Hygiene and Treatment in nursing and Midwifery, Tehran. Iran University of Medical Science; 2000: 56.[Persian]
10- Jansen N, Van Amelsvoort L, Kristensen T, Van denBrandt P, Kant I. Work schedules and fatigue: aprospective cohort study. Occupational and EnvironmentalMedicine, 2003; 60(1):i47-i53.
11- Arghami s, Kamali k, Radanfar F. The work load of the performing task in nursing job in different department of a hospital. Occupational Health Engineering, 2015; 3: 45-54. [Persian]
12- DeLucia PR, Ott TE, Palmieri PA. Performance in nursing. Reviews of human factors and ergonomics. 2009;5(1):1-40.
13- Donchin Y, Gopher D, Olin M, Badihi Y, Biesky MR, 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):294-300.
14- Bakr M, Atalla H. Medication errors,causes, and reporting behaviors as perceived by nurses. JPBMS, 2012;19(17).
15- Lyons M,woloshynowych M, Adams S, Vincent Ch. Error Reduction in medicine.
16- Chang D. applications of the extent analysis method on fuzzy AHP. European journal of operational research, 1996; 95: 649-655.
17- Chen, S.J., Hwang, C.L., "Fuzzy multiple attribute decision-making, Methods and Applications", Springer, Heidelberg: 1993.
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1- Hunszu L, Sheue-Ling H, Thu-Hua L. Economic assessment of human errors in manufacturing environment, Safety Science, 2009; 47: 170–182.
2- Ghasemi M, Jebraiel S, Zakerian SA. Study of ergonomic (Identification, prediction and control) of Human Error in One of Control Room of the petrochemical plant by SHERPA Technique. J Health School and Health research Institute, 1389; 8(1): 5-412. [Persian]
3- kirwan B. A Guide to Practical Human Reliability Assessment. TYLOR and FRANCIS; 1994: 592.
4- Kariuki, SG, Löwe K. Integrating human factors into process hazard analysis. Reliability Engineering and Safety, 2007; 92(12): 1764-73.
5- Ramin Z. Human Error Assessment in Cement Factory with HRMS Method: University of Tehran; 1996.
6- Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. The Lancet, 1997;349(9048):309-13.
7- Moghadam S, Zakerian SA. Ergonomic inHealth care system- Human factor models. Health and safety at work; 2016: 4. [Persian]
8- Aghdami M, Alhani F. The barriers & presentation of solution for performing tasks specific Tehran's children nursery in children hospital. [Persian]
9- Moshiri Z, Rostamzade M, Amlashi S. The survey of knowledge and procced nursing students in their professional duties in Uromia Medical Science University. Congress of Coordination of Education. Hygiene and Treatment in nursing and Midwifery, Tehran. Iran University of Medical Science; 2000: 56.[Persian]
10- Jansen N, Van Amelsvoort L, Kristensen T, Van denBrandt P, Kant I. Work schedules and fatigue: aprospective cohort study. Occupational and EnvironmentalMedicine, 2003; 60(1):i47-i53.
11- Arghami s, Kamali k, Radanfar F. The work load of the performing task in nursing job in different department of a hospital. Occupational Health Engineering, 2015; 3: 45-54. [Persian]
12- DeLucia PR, Ott TE, Palmieri PA. Performance in nursing. Reviews of human factors and ergonomics. 2009;5(1):1-40.
13- Donchin Y, Gopher D, Olin M, Badihi Y, Biesky MR, 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):294-300.
14- Bakr M, Atalla H. Medication errors,causes, and reporting behaviors as perceived by nurses. JPBMS, 2012;19(17).
15- Lyons M,woloshynowych M, Adams S, Vincent Ch. Error Reduction in medicine.
16- Chang D. applications of the extent analysis method on fuzzy AHP. European journal of operational research, 1996; 95: 649-655.
17- Chen, S.J., Hwang, C.L., "Fuzzy multiple attribute decision-making, Methods and Applications", Springer, Heidelberg: 1993.
