Reducing chronic medical complications due to failure of patient safety using Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) method

Authors

  • Mohammad Reza Modabber Department of Health Care Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran https://orcid.org/0000-0003-4193-0629
  • Batoul Ahmadi Department of Health Care Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran https://orcid.org/0000-0001-9536-8235
  • Ali Mohammad Mosadeghrad Department of Health Care Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

DOI:

https://doi.org/10.22122/cdj.v7i4.466

Keywords:

Medical Error, Risk, Analysis, Nursing, Iran

Abstract

BACKGROUND: Human errors in the medical profession can lead to irreparable errors in people's lives, damage, and heavy costs. Among health care workers, nurses spend more time with patients compared to other personnel; hence, they are more prone to human error. Therefore, the purpose of this study was to identify and evaluate human errors using the Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) method in nursing staff of a general hospital in Qazvin Province, Iran.

METHODS: This cross-sectional study was conducted in a general hospital in Qazvin during last 6 months of 2016 and first 6 months of 2017. The target population in the present study was nursing groups based on their highest work experience, from each section in hospital. The SPAR-H method was used to investigate human error in the population and the collected data were analyzed using SPSS software.

RESULTS: The highest error related to inappropriate venipuncture with probability of 0.7, and the least probable error related to error in entering the numbers of vital signs with the probability of 0.0045.

CONCLUSION: Due to the sensitivity of the role of nurses in hospitals, the need for increased workforce, the use of people with higher work experience in sensitive sectors, reducing overtime even for those who volunteered to work overtime, scientific scheduling of the personnel’s work shifts, and providing practical training such as stress control methods in case of emergencies can be effective in reducing the probability of an error.

References

Haji Hoseini A. Engineering of human error. 1st ed. Tehran, Iran: Fanavaran Publications; 2010. p. 45-66,143-101. [In Persian].

Kallberg AS, Goransson KE, Ostergren J, Florin J, Ehrenberg A. Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients -a national review. Eur J Emerg Med 2013; 20(1): 33-8.

Guillod O. Medical error disclosure and patient safety: Legal aspects. J Public Health Res 2013; 2(3): e31.

Soop M, Fryksmark U, Koster M, Haglund B. The incidence of adverse events in Swedish hospitals: A retrospective medical record review study. Int J Qual Health Care 2009; 21(4): 285-91.

Dhingra KR, Elms A, Hobgood C. Reducing error in the emergency department: A call for standardization of the sign-out process. Ann Emerg Med 2010; 56(6): 637-42.

Anderson JG, Jay SJ, Anderson M, Hunt TJ. Evaluating the impact of information technology on medication errors: A simulation. J Am Med Inform Assoc 2003; 10(3): 292-3.

Kalra J, Kalra N, Baniak N. Medical error, disclosure and patient safety: A global view of quality care. Clin Biochem 2013; 46(13-14): 1161-9.

DeLucia PR, Palmieri PA. Performance in nursing. Reviews of Human Factors and Ergonomics 2009; 5: 1-40.

Barker LM, Nussbaum MA. The effects of fatigue on performance in simulated nursing work. Ergonomics 2011; 54(9): 815-29.

Kunert K, King ML, Kolkhorst FW. Fatigue and sleep quality in nurses. J Psychosoc Nurs Ment Health Serv 2007; 45(8): 30-7.

Newman KM, Doran D. Critical care nurses' information-seeking behaviour during an unfamiliar patient care task. Dynamics 2012; 23(1): 12-7.

Treiber LA, Jones JH. Devastatingly human: An analysis of registered nurses' medication error accounts. Qual Health Res 2010; 20(10): 1327-42.

Davis RE, Sevdalis N, Neale G, Massey R, Vincent CA. Hospital patients' reports of medical errors and undesirable events in their health care. J Eval Clin Pract 2013; 19(5): 875-81.

Gertman DI, Blackman HS, Marble JL, Byers JC, SmithIdaho CL. The SPAR-H Human Reliability Analysis Method (NUREG/CR-6883, INL/EXT-05-00509). Idaho Falls, Idaho: Idaho National Laboratory; 2005.

Institute of Medicine, Committee on Quality of Health Care in America. To Err is human: Building a safer health system. Washington, DC: National Academies Press; 2000.

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The canadian adverse events study: The incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170(11): 1678-86.

Tanha F, Mazloumi A, Faraji V, Kazemi Z, Shoghi M. Evaluation of human errors using standardized plant analysis risk human reliability analysis technique among delivery emergency nurses in a hospital affiliated to Tehran University of Medical Sciences. Hospital 2015; 14(3): 57-66.

Khandan M, Yusefi S, Sahranavard R, Koohpaei A. SHERPA technique as an approach to healthcare error management and patient safety improvement: A case study among nurses. Health Scope 2017; 6(2): e37463.

Shepherd A. HTA as a framework for task analysis. Ergonomics 1998; 41(11): 1537-52.

Bell J, Holroyd J. Review of human reliability assessment methods. Harpur Hill, UK: Health & Safety Laboratory; 2009.

Shamsaii M, Faraji O, Ramazani A, Hedaiati P. The viewpoints of Zabol's general practitioners about medical errors in 2010. Hospital 2012; 10(4): 31-6.

Malekzadeh R, Araghian Mojarrad F, Amirkhanlu A, Sarafraz S, Abedini E. Incidence of medical errors in voluntary reporting system in hospitals of Mazandaran University of Medical Sciences in 2014. Manage Strat Health Syst 2016; 1(1): 61-9. [In Persian].

Desai RJ, Williams CE, Greene SB, Pierson S, Caprio AJ, Hansen RA. Exploratory evaluation of medication classes most commonly involved in nursing home errors. J Am Med Dir Assoc 2013; 14(6): 403-8.

Manias E, Kinney S, Cranswick N, Williams A. Medication errors in hospitalised children. J Paediatr Child Health 2014; 50(1): 71-7.

Hewitt P. Nurses perceptions of the causes of medication errors: An integrative literature review. Medsurg Nursing 2010; 19(3): 159-67.

Downloads

Published

2019-09-23

How to Cite

1.
Modabber MR, Ahmadi B, Mosadeghrad AM. Reducing chronic medical complications due to failure of patient safety using Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) method. Chron Dis J. 2019;7(4):272–278.

Issue

Section

Original Article(s)

Most read articles by the same author(s)