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

Iraj Mohammadfam, Saeid Bashirian, Zohreh Bakhshi

Abstract


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.

Keywords


Human Errors, Critical Processes, Hospital, Extended CREAM

Full Text:

PDF XML

References


Stock GN, McFadden KL and Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. International Journal of Production Economics. 2007;106(2):368-392.

Rubin G, George A, Chinn D, Richardson C. Errors in general practice: development of an error classification and pilot study of a method for detecting errors. Quality and Safety in Health Care. 2003;12(6):443-47.

Mohammadfam I, Movafagh M, Bashirian S. Comparison of Standardized Plant Analysis Risk Human Reliaşbility Analysis (SPAR-H) and Cognitive Reliability Error Analysis Methşods (CREAM) in Quantifying Human Error in Nursing Pracştice. Iranian journal of public health. 2016;45(3):401-2.

Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000;320(7237):774–77.

Lee BH, Lehmann CU, Jackson EV, Kost-Byerly S, Rothman S, Kozlowski L, Miller MR, Pronovost PJ, Yaster M. Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home. The Journal of Pain. 2009;10(2):160-6.

Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. Global trigger tool’shows that adverse events in hospitals may be ten times greater than previously measured. Health affairs. 2011; 30(4):581-89.

Mohammadfam I, Saeidi C. Evaluating human errors in cataract surgery using the SHERPA technique. Journal of Ergonomics. 2014;2(4):41-46. [Persian].

Kopec D, Kabir MH, Reinharth D, Rothschild O, Castiglione JA. Human errors in medical practice: systematic classification and reduction with automated information systems. Journal of medical systems. 2003;27(4):297-313.

Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S. Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 2016; (21):2541-56.

Clarke DL, Aldous C, Thomson SR. The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education. Injury, Int J Care Injured. 2014;45:285-88.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Economic Measurement of Medical Errors Using a Hospital Claims Database Value In Health. 2013;16(2):305-10.

Mazlomi A, Kermani A, Nasleseraji J, Ghasemzadeh F. Identification and assessment of human error by using the SHERPA method in the Imam Ali hospital emergency physicians working in Semnan. Journal of Occupational Medicine. 2013;5(3):67-78. [Persian]

Spanu F, Baban A, Briaa M, Lucacel R, Florian IS, Rus L. Error communication and analysis in hospitals: the role of leadership and interpersonal climate. Procedia - Social and Behavioral Sciences. 2013;84:949-53.

Mohammadfam I, Mansouri N, Nikoomaram H, Ghasemi F. Comparison of Commonly Used Accident Analysis Techniques for Manufacturing Industries. International Journal of Occupational Hygiene. 2015;7(1):32-37.

Mohammadfam I, Nikoomaram H, Lotfi FH, Mansouri N, Rajabi AA, Mohammadfam F. Development of a Decision-Making Model for Selecting and Prioritizing Accident Analysis Techniques in Process Industries. J Sci Ind Res India. 2014;73(8):517-20.

Mazlomi A, Hamzeiyan M, Dadkhah A, Jahangiri M, Mohadesi P. Assessment of Human Errors in an Industrial Petrochemical Control Room using the CREAM Method with a Cognitive Ergonomics Approach. Scientific Journal of School of Public Health and Institute of Public Health Research. 2011;8(4):15-30. [Persian]

Mohammadfam I, Movafagh M, Soltanian A, Salavati M, Bashirian S. Identification and Evaluation of Human Errors among the nurses of Coronary Care Unit Using CREAM Technique. Journal of Ergonomics. 2014;2(1):27-35. [Persian]

Mortazavi SB, Mahdavi S, Asilian H, Arghami S, Gholamnia R. Identification and Assessment of Human Errors in SRP Unit of Control Room of Tehran Oil Refinery Using HEIST Technique (2007). journal of kermanshah university of medical sciences. 2008;12(3):308-22.

Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human error analysis among petrochemical plant control room operators with human error assessment and reduction technique. ioh. 2009;6(2) :38-50.

Stanton NA. Hierarchical task analysis: Developments, applications, and extensions. Applied Ergonomics. 2006;37(1):55-79.

Akyuz E, Celik M. Application of CREAM human reliability model to cargo loading proce ss of LPG tankers. Journal of Loss Prevention in the Process Industries. 2015;34(1):39-48.

Peng-cheng L, Guo-hua C, Li-cao D, Li Z. Fuzzy logic-based approach for identifying the risk importance of human error. Safety Science. 2010;48(7):902-13.

Al-Hakim L, Sevdalis N, Maiping T, Watanachote D, Sengupta S, Dissaranan C. Human error identification for laparoscopic surgery: Development of a motion economy perspective. Applied ergonomics. 2015;50 (1):113-25.

Rolston JD, Bernstein M. Errors in Neurosurgery. Neurosurgery Clinics of North America. 2015;26(2):149-55.

Hwang J-I, Ahn J. Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals. Asian Nursing Research. 2015;9(1):14-20.

Joise P, Hanna GB, Cuschieri A. Errors enacted during endoscopic Surgery-a human reliability analysis. Applied Ergonomics. 1998; 29(6): 409-14.

Dastaran S, Hashemi-nejad N, Shahravan A, Baneshi MR, faghihi A. Identifiation and Assessment of Human Errors in Postgraduate Endodontic Students of Kerman University of Medical Sciences by Using the SHERPA Method. Journal of Occupational Hygiene Engineering. 2016;2(4):44-51. [Persian].

Khammarnia M, Ravangard R, Jahromi M, Moradi A. A Study on the Medical Errors in Public Hospitals of Shiraz, 2013. Hospital. 2014:17-24. [Persian]

Guchelaar HJ, Colen HB, Kalmeijer MD, Hudson PT, Teep-Twiss IM. Medication Errors: hospital pharmacist perspective. Drugs. 2005;65(13):1735-46.

Ruiz ME, Suñol MM, Miguélez JR, Ortiz ES, Urroz MI, de Lamo Camino M, et al. Medication errors in a neonatal unit: One of the main adverse events. Anales de Pediatría (English Edition). 2016;84(4):211-17.

Lasseter JH, Warnick ML. Medical errors, drug-related problems, and medication errors: a literature review on quality of care and cost issues. J Nurs Care Qual. 2003; 18(3): 175-83.

Prot S, Fontan JE, Alberti C, Bourdon O, Farnoux C, Macher MA, Foureau A, Faye A, Beaufils F, Gottot S, Brion F. Drug administration errors and their determinants in pediatric in-patients. International Journal for Quality in Health Care. 2005;17(5):381-89.

Jolaee S, Hajibabaee F, Peyravi H, Haghani H. Nursing medication errors and its relationship with work condition in Iran University of Medical Sciences . ijme. 2009;3(1):65-76.

Beydokhti TB, Mohammadpour A, Shabab S, Nakhaee H. Related factors of medication errors and barriers of their reporting in the medical staff in hospitals of Gonabad University of Medical Sciences. Quarterly of the Horizon of Medical Sciences. 2014;19(5):289-95.

Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.

Taheri E, Nourian M, Rasouli M, Kavousi A. The Study of Type and Amount of Medication Errors in Neonatal Intensive Care Units and Neonatal units. Iran J Crit Care Nurs. 2013;6(1):21-28. [Persian]

Azadeh A, Rouhollah F, Davoudpour F, Mohammadfam I. Fuzzy modelling and simulation of an emergency department for improvement of nursing schedules with noisy and uncertain inputs. International Journal of Services and Operations Management. 2013;15(1):58-77.




Iranian Journal of Health, Safety and Environment e-ISSN: :2345-5535 Iran university of Medical sciences, Tehran, Iran