Evaluation of Human Errors Using Standardized Plan Analysis Risk among Health Provider in Clinical and Pathology Laboratories in Hospitals of Qazvin Province

Author Name(s): Seyed Amir Farzam, Zohre Sahraei, Elham Khodabandehloo, Habib Sadeghi Rad, Mohammad Reza Modabber, Yousef Khazaei Monfared
Author Email: khazaei_yoosef@outlook.com

Abstract

Damage due to human error has different consequences in different professions. Small mistakes can lead to irreparable damages and high costs in the health care profession. Therefore, the purpose of this study was to identify human error using the SPAR-H in clinical and pathology laboratories in hospitals of Qazvin province. Method: This study was a cross-sectional study which was conducted in 15 hospitals of Qazvin in 2018. The target groups was of professional staff in clinical and pathology laboratories comprised 150 staffs who they were included as an available sampling . At first, task analysis was conducted to target group using Hierarchical Task Analysis (HTA) technique by FGD. In next step, the Human Error Probability (HEP) was determined utilizing SPAR-H method and dependences of performance-shaping factors (PSFs) and action and diagnosis activities were identified. And finally, the errors were detected. Result: According to the findings of the study, in the laboratory, 12% of the diagnostic errors, 48% of the functional and 40% of the compound were evaluated. The most probable error was the error in entering the results and values from the manual recording to the computer with a 1% probability error and the least probable error was the Corrupted or lost samples with an error probability of 0.00125%. Conclusion: Considering the fact that the highest number of reported errors occurred at the patient’s admission stage, including the inclusion of patient information and incorrect registration of the requested tests, and given the high volume of patients referred to hospital laboratories, especially public hospitals due to acceptance of treatment insurance And the low cost, it is necessary to allocate more personnel in the acceptance and response department.

Introduction

Human errors are one of the issues that have attracted a considerable part of the time, budget, and attention of specialists and managers in the world of theoretical and practical management today. The organizational structure of the staff of an organization is one of the factors that plays an effective role in reducing human error.(1) Damage due to human error has different consequences in different professions and small mistakes can lead to catastrophic dimensions in important and sensitive businesses. Human errors that deals with the lives of people can lead to irreparable damages and high costs in the health care profession.(2-3) Human errors in the medical profession called medical error are The failure to do the right thing or the wrong acts in planning or execution that inactivates or potentially causes an unwanted event that results in death, prolongation of hospitalization or disability when discharged. These mistakes include diagnostic errors, mistakes in prescribing drugs and therapies, errors in surgical procedures, mistakes in the use of technology and equipment, mistakes in the interpretation of Para clinical tests, etc.(4)The review of resources shows that the mistakes of medical professions are less studied than other occupations in Iran and other countries.

Conclusion

Since laboratories have a high impact on patient safety and 80-90% of medical diagnosis are based on the results of laboratory tests, errors in laboratory tests lead to delay in treatment or treatment, and thus additional costs and increased costs Causes the patient’s dangers.[8] Considering the fact that the highest number of reported errors occurred at the patient’s admission stage, including the inclusion of patient information and incorrect registration of the requested tests, and given the high volume of patients referred to hospital laboratories, especially public hospitals due to acceptance of treatment insurance And the low cost, it is necessary to allocate more personnel in the acceptance and response section, and it seems that the establishment of a system that is in terms of the quality of the laboratory support and can, in addition to the control of the laboratory, cover the errors and errors and correct training , can play an effective role in reducing the errors of laboratory.

 

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