IDENTIFICATION, EVALUATION AND PRIORITIZATION OF HUMAN ERRORS IN THE NURSING POPULATION OF THE HOSPITAL'S CORONARY CARE UNIT

Every year, many patients in different wards of the hospital die due to human error. One of the important aims in the field of human errors related to clinical care is to identify and prevent the occurrence of harmful effects caused by such errors. One of the preventive approaches in order to prevent human errors 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 and Materials:

 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 two software that used to analyze data in this study.

Among the 116 identified errors with SHERPA, the highest percentages of errors identified from the total errors were related to the functional error (68.1%) and lowest percentages 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 which affecting the occurrence of human errors in the CCU. By pair comparison of this factors, we founded that experience and skill of nurses, with a weight of 0.278 and 0.272, have the most important and factor of equipment with a weight of 0.087, had the lowest important among the five effective factors for incidence of human error in the CCU. The task of extracting airway discharge with a weight of 0.125 was the most preferred among 16 tasks, in other words task of extracting airway discharge was the most risk of error in functional error. Factor of experience and skill as the most important factor in the occurrence of functional error. In the error type of recovery, the task of identifying drug information (time, date, dose and dosage form, etc.) with a weight of 0.054 was the highest rank in this type of error. The factor of experience and loading with weights of 0.018 and 0.01 were the most important, respectively in this type.

In the coronary care unit, functional and revisions errors in the vital tasks such as cardiopulmonary resuscitation, dose adjustment, and proper drug injection were the most common. Therefore, design and implementation of control measures such as periodic training on how to do the job properly, preparation of checklists with a focus on human behavior in different job processes recommended to eliminate or reduce the amount of identified errors in the hospitalchr('39')s CCU.