Showing 10 results for Human Error
Iraj Mohammadfam, Maryam Movafagh, Alireza Soltanian, Mohsen Salavati, Saeid Bashirian,
Volume 2, Issue 1 (6-2014)
Abstract
Background: Adverse events are injuries and problems are derived from management than the original condition. In particular, Intensive care units are as a place of significant human errors and preventable adverse events in the health care system. The present study was conducted to identify and evaluate human errors among cardiac intensive care nurses in a teaching hospital in Hamadan city.
Materials and Methods: This qualitative study was conducted using the cream technique. in this study nursing job were analyzed using hierarchical task analysis. Then the work sheet of cream techniques completed through observation and interviews with the nurses. Data analysis was performed using spss-16 software.
Results: Findings show that the maximum probability of error are in setting tasks and use DC shock in urgent cases, data recording in the hospital system, said start code resuscitation of heart and lung (CPR) respectively 0.02108, 0.02088 and 0.02086. Minimum probability of error were Determine nutritional needs and diet, gavages and necessary care and giving oral medications respectively 0.01100, 0.01013 and 0.00966.
Conclusions: The most important suggestion to improve of working situation and reducing of human error probability are modification of nurses shift work, providing of practical training and decrease of additional duties.
Gholamabbas Shirali, Afshin Dibeh Khosravi, Taher Hosseinzadeh, Asad Fathi, Masood Hame Rezaee, Mostafa Hamzeiyan Ziariani,
Volume 2, Issue 3 (12-2014)
Abstract
Introduction: In many
sensitive and sophisticated workplaces, human errors are very important. Many
events occur annually around the world is evidence to confirm error due to the
data processing operators. The main goal of this study was to investigate human
information processing models and workload demands on human operators, then
developing a regression model for this purpose.
Material and Methods: This was a case study. Task analysis of control room
members, including shift supervisor, board man, and site man and user
instrumentation in this study was investigated. Data collection was performed
by interviewing employees using a questionnaire with two parts the first part
was the model of human information processing and the second part was workload
NASA–TLX and an appendix of opinions existing staffing level and finally task
analysis performed using SPSS 16 – SPSS.
Results: There was a correlation between workload and stages of
human information processing model such as perception )r=0.65, p<0.01), vocal response (r=0.45, p<0.01)
and manual response (r=0.15, p<0.05). Some effective factors on workload
were vocal response (β=0.232, p=0.033) and perception (β=0.576, p=0.00). The
most important factors in the analysis of anticipation staffing demand were
perception (β=2.514, p=0.008), workload (β=1.57, p=0.018) and vocal responses
(β=2.428, p=0.01), respectively.
Discussion and Conclusion: Increasing
concentration and attention and perception skills using psychological measures
including decreasing the workload and stress and holding specialized training
courses are necessary.
Iraj Mohammadfam, Chiman Saeidi,
Volume 2, Issue 4 (3-2015)
Abstract
Introduction: Human errors
result in numerous accidents in healthcare professions every year and lead to
the death of many patients. Considering the high rate of eye cataract surgeries
performed in Iran and the sensitive nature of the surgery, the present study
was conducted to identify and assess possible human errors in the performance
of these surgeries.
Materials and
Methods: The present qualitative, cross-sectional study was conducted to identify
and assess human errors in the process of eye cataract surgery using the SHERPA
technique. At first, using the hierarchical task analysis method,
the surgery process was divided into tasks and sub-tasks. In the next step,
through the same technique, possible human errors were detected and
risk-assessed. Appropriate prevention solutions were then proposed for reducing
the risk of errors.
Results: A total of 53
possible errors were detected for the 41 tasks in the surgery process. The
highest error percentages pertained to performance and the lowest pertained to
retrieval. Moreover, the risk of 22.64% of the errors detected was deemed
unacceptable.
Conclusions: Given the
severity of the outcomes of human errors in cataract surgery, reducing the rate
of the detected errors is crucial. According to the type and frequency of the
detected errors, the findings of the present study emphasize the importance of
designing and implementing behavior-based safety training programs for
ophthalmologists.
Elham Pakdel, Manochehr Omidvari,
Volume 5, Issue 1 (6-2017)
Abstract
Introduction: One of the most important issues in industries is accident. Various factors affect these events, one of which is individual features. This study aimed at investigating the role of human resource personality on human reliability in accident outbreaks using DISC behavioral approach modal in automotive industry.
Methods: This was a descriptive-analytical research. The relationship of person vulnerability with human personality with fallibility was investigated. In order to determine human personality disk standard model was used and to estimate the degree of human fallibility heart techniques were used. Then, the relationships of natural personality, human reconcilable dimensions, human reliability and fallibility were found. Also, the relationship of accident repetition with personality and human fallibility was determined. This research was conducted among 98 personnel of one of the biggest production units during 2013 to 2015.
Results: The results indicated that there was a high correlation in human personality and fallibility dimension with accidents outbreak. There was a significant relationship between persons with influential personality, inherent stability, adapted stability, adapted dutiful, and accident outbreak repetition.
Conclusions: According to the results, the personality of individuals with high sensitivity in their job and less adaptation to changes made in work environment, has a higher possibility of accidents outbreaks. Perhaps, this issue is created because of the inconsistency between the management system that is ruling the industry of developing countries and personality features of those people.
Iraj Mohammadfam, Tahere Eskandari, Maryam Farokhzad,
Volume 6, Issue 3 (10-2018)
Abstract
Background and Objectives: The main cause of incidents is human error. The occurrence of these errors in the use of medical equipment can result in harm to the patient, the destruction of equipment, the imposition of economic damages, and the deterioration of the credentials of the health sectors. Hence, the identification, evaluation and management of errors in the use of these equipment is very critical. The present study was conducted to reduce the risk of human errors in using a medical device in one of the hospitals in Iran.
Methods: The study subject was a ventilator device, which was selected considering the high usage and the criticality of its use in hospitals. Identification and evaluation of human error were performed using the PUEA technique, as well as quantification of errors, and reduction of uncertainty in estimating the significance of detected human errors using fuzzy logic.
Results: Based on the findings, 33 errors were detected in the use of the ventilator device. The most common types of errors were the type of error in operation. (72.72%). The most important causes of errors were slips and lapses (42.42%). The main primary consequences for the predicted errors were the device not being sterilized and the possibility of transmission of microbes to patients. In 42.42% of the cases, errors were not recoverable. The results of the PUEA technique and fuzzy logic showed that there is no relationship between the type of error, frequency of its occurrence, and the probability of error occurrence.
Conclusion: In human error studies, the combined use of risk identification techniques and a quantitative approach that determines the probability of identified errors can reduce uncertainty in the final results.
Mahnaz Shakerian, Dr Alireza Choobineh, Dr Mehdi Jahangiri, Dr Moslem Alimohammadlou, Dr Mohammad Nami,
Volume 6, Issue 4 (3-2019)
Abstract
Background and Objectives: The recognition of a system failure causes and their related factors are considered as the most important factor in preventing accident occurrence in different organizations including industries. Human error is a known important factor in unpredictable events of which cognitive factors are the most influential ones. The purpose of this study was to introduce a new model for individual cognitive factors influencing human error as well as determining the interactions between the factors and their intensity using DEMATEL approach.
Methods: First a qualitative study was performed in order to identify and elicit the individual cognitive factors influencing human error among the workers of different industries. To ensure the adequacy and comprehensiveness of the elicited factors, then, the experts’ opinion was applied. DEMATEL method was used for understanding the interactions among the individual cognitive factors influencing human error. Finally, using these relationships, a new model of the study was proposed.
Results: Calculating D-R and D+R relating to the factors in terms of being cause or effect factor, D-R was -1.213 for C5 as the highest negative value, and D+R was 2.294 for the same factor (C5). Also, threshold level was calculated as 0.087 in the current study
Conclusion: In this study, the factors of failure in problem solving and decision making (C5) and difficulty in predicting possible hazards in the workplace are effects and the other factors were the cause factors. The factor of C5 was the highest interactive factor.
Zeinab Rasouli Kahaki, Somayeh Tahernejad, Razieh Rasekh, Mehdi Jahangiri,
Volume 7, Issue 3 (11-2019)
Abstract
Background and Objectives: Human errors in dialysis care can cause injury and death. One of the basic steps to increase reliability in this critical process is to analyze the error and identify the weaknesses of doing this process.
Methods: The present study is a descriptive-analytic cross-sectional study. The SPAR-H method was used to identify and evaluate the probability of human error in the dialysis process. The hospital had six dialysis department and 16 dialysis machines with two nurses in each department. Data collection was done by observing the dialysis process, interview with nurses, reviewing the documents, methods of work and work instructions.
Results: The present study showed that the probability of human error in the duties of a dialysis nurse is in the range of 0.02-0.44 (except for devices related to disorder), which is related to sub-duty preparing patient as lowest rate and sub-duty of the pump set-off as highest error rate.
Conclusion: To reduce and control the human error in nursing duties in the dialysis department, control measures should be done such as increasing the number of personnel, changing the time shift of nurses, and training, preparing and revising the instructions.
Marzieh Abbassinia, Omid Kalatpour, Majid Motamedzadeh, Alireza Soltanian, Iraj Mohammadfam,
Volume 8, Issue 2 (6-2020)
Abstract
Background and Aim: Petrochemical industry is one of the most accident-prone industries, and most accidents in this industry are related to human factors. The principles of Lean production are one of the approaches used to improve the production situation. Various studies have shown that implementing Lean production improves the safety and ergonomics. In this study, the principles of Lean production were used to reduce human error and improve response in emergencies.
Methods: The basic CREAM method was used to evaluate human errors. In order to select Lean production tools appropriate to the emergency response tasks, the opinions of the 20-member panel of specialists and experts, including industry managers, HSE officials, and university professors, were used. For examining the impact of Lean production principles on reducing human error in emergencies, 6 months after the implementation of Lean production interventions, human error was re-examined. Evaluation of human errors after Lean production interventions was also performed by basic CREAM method.
Results: The results of the evaluation of human errors before and after the implementation of Lean production interventions showed that the level of control mode of the three sub-tasks improved from the tactical control mode to the strategic control mode. The most probable human error was in evacuate sub-task.
Conclusion: The results of this study showed that the implementation of those interventions that in addition to improving the level of safety, can improve organizational productivity, is more accepted by industry management.
Tahmineh Moradi Tamadon, Fakhradin Ghasemi, Iraj Mohammadfam, Omid Kalatpour,
Volume 8, Issue 4 (1-2021)
Abstract
Background and Objectives: Firefighting is a difficult and dangerous job. This job requires decision-making and speed in action in critical situations. Such conditions increase the probability of human error in the firefighting activities. Setting up fire operators as the first step of emergency response is associated with high criticality. The purpose of this study is identification and assessment of the risk of human error while setting up and operating fire operators.
Methods: This descriptive cross-sectional study was performed in 2019. Tasks related to the operation of industrial firefighting operators were studied and analyzed by Hierarchical Task Analysis. Then, human errors in the operation of fire operators were identified and analyzed using the systematic human error reduction and prediction approach (SHERPA). Finally, appropriate prevention solutions were proposed to reduce the risk of errors.
Results: A total of 480 errors were detected for 130 tasks as 49.58% of them were action errors, 39.17% check type, 10.42% communication and 0.83% were selective errors and no retried error was observed. According to the results of risk assessment, 8.33% of the errors were unacceptable, 24.17% were undesirable, and 48.33% were acceptable risks but needed to be revised and 19.17% were acceptable without the need for revision.
Conclusion: The process of operating fire operators can be associated with human errors and prevent successful firefighting operations. Therefore, these errors should be identified and controlled using appropriate methods.
Fatemeh Karami, Samira Ghiyasi, Ahmad Soltanzadeh,
Volume 8, Issue 4 (1-2021)
Abstract
Background and Objectives: ِِDespite complex technologies in many work environments, human errors are of great importance as they might lead to severe and catastrophic accidents. Therefore, in order to prevent and limit the consequences of human error, it seems necessary to identify and find the causes of them. The aim of this study was to identify and evaluate the human errors of locomotive maneuvers in the railway repair and development project, 2019.
Methods: In this cross-sectional study, the identification and evaluation of human errors in locomotive maneuvers in the MAPNA railway repair and development project using SHERPA technique was done. First, using the hierarchical task analysis method, the activities of the maneuvers are divided into their tasks and sub-tasks; in the next step, the types of human errors in each of the tasks were identified and then human errors were evaluated according to SHERPA instruction.
Results: A total of 206 errors were identified in the present study. Errors included 48.5% action error, 39.8% checking error, 10.2% information communication error and 1.5% selection error. The lowest and highest errors related to locomotive displacement error were related to hot single diesel (14.0%) and locomotive displacement error on service pit (29.6%). Of the identified errors, 23.8% had an unacceptable risk level, 51.1% had an ALARP risk level and 25.2% had an acceptable risk level.
Conclusion: The findings of the study indicated that the most unacceptable risks and ALARP were related to checking and action error, respectively. So, it is suggested that the design and implementation of control measures related to these two types of errors should be prioritized.
