Evaluation and Management of Human Errors in Critical Processes of Hospital Using the Extended CREAM Technique

Iraj Mohammadfam, Saeid Bashirian, Zohreh Bakhshi


Medical errors result in serious and often-preventable problems for patients. Human errors can be used as an opportunity for learning as well as a key factor for patients’ safety improvement and quality of patients' surveillance in hospitals. The aim of the present study was to identify and evaluate human errors to help reduce risks among personnel who render health services during critical hospital processes. This cross-sectional study was done in the Besat hospital in Hamedan in 2016. At first, the critical processes were selected via given scores in Delphi method and by multiplying the scores of each of the five criteria including the severity of the consequences caused by error incidence, probability of error, capability of the error detection, task repeatability and type of hospital ward with each other. Determining the risk numbers of each process, three ones were chosen with the largest scores. At the end, the selected processes were analyzed by the method of extended CREAM. The results showed that the highest CFP is associated with the CPR process, particularly in the sub-stage of command of starting CPR by anesthesiologists (0.0891), the one in the giving medicine process is in the sub-stage of calculating of medicine dozes and determining prescription methods (0.0796) and also the one in the tracheal intubation process is in the sub-stages of pulmonary and respiratory monitoring of patients and observing the vocal cords and larynx of patients (0.0350). Regarding the critical consequences of human errors in the selected processes, reviewing the qualities of roles and responsibilities of each of the medical group members and providing specialized introduction for hospital processes seem necessary.


Human Errors, Critical Processes, Hospital, Extended CREAM

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