Identification, Evaluation and Prioritization of Human Errors in the Nursing Population of the Hospital's Coronary Care Unit



Garmaroudi AA¹ ; Mozaffari S¹ ; Bahrami M¹ ; Alimoradi H²
Source: Iran Occupational Health Published:2021

Abstract

Background and aims: Every year, many patients in different wards of the hospital die due to human errors. In the field of human errors related to clinical care, one of the most important aims is to identify and prevent the occurrence of harmful effects caused by such errors. Thus, in order to prevent human errors, one of the preventive approaches is to recognize and analyze them. The purpose of this study is, to investigate all clinical care processes in the coronary care unit, identify human errors and prioritize the tasks and errors in this section. Methods: This descriptive-analytical study was performed cross-sectional in three stages. In the first stage, human errors were identified and evaluated using the SHERPA approach, and the frequency of each human error in the CCU was determined. In the second stage, the criteria and factors affecting the occurrence of human error in the CCU were determined by Delphi method. Finally, in the third stage, with the Analytic hierarchy process, the criteria and tasks that had the highest frequency of errors, were prioritized. SPSS.24 and Expert choice.11 are the two softwares that were used to analyze the data in this study. Results: Among the 116 identified errors with SHERPA, the highest percentages of identified errors among all the errors, were related to functional errors (68.1%) and the lowest percentages was related to selective errors (2.58%), respectively. The results of different Delphi rounds showed that the factor of skill, experience, equipment, work time and workload are the most important factors that affect the occurrence of human errors in CCU. By pair comparison of this factors, we found that the experience and skill of the nurses, with a weight of 0.278 and 0.272, was the most important, and the equipment’s factor with a weight of 0.087, was the least important among the five effective factors for the incidence of human errors in CCU. The task of extracting airway discharge with a weight of 0.125, was the most preferred among 16 tasks, in other words, the task of extracting the airway discharge had the most risk for error amongst all the functional errors. The factor of experience and skill, was the most important factor in the occurrence of functional errors. In the error type of recovery, the task of identifying the drug information (time, date, dose and dosage form, etc.) with a weight of 0.054, had the highest rank among this type of errors. The factor of experience and loading with weights of 0.018 and 0.01, were the most important among this type, respectively. Conclusion: In the coronary care unit, the functional and revision errors in the vital tasks such as cardiopulmonary resuscitation, dose adjustment, and the lack of proper drug injection, were the most common errors among all. Therefore, design and the implementation of control measures such as periodic trainings on how to do the job properly, preparation of checklists with a focus on human behavior in different job processes, is recommended to eliminate or reduce the amount of identified errors in the hospital's CCU. © 2021 Iran University of Medical Sciences. All rights reserved.