Ghasemi Mohammad, Khoshakhlagh Amir Hossein, Mahmudi Sadrollah, Fesharaki Mohammad Gholami
a Health Research Center, Baqiyatallah University of Medical sciences , Tehran , Iran.
b Department of Occupational Health , Shahid Sadoughi University of Medical Sciences and Health Services , Yazd , Iran.
Int J Occup Saf Ergon. 2015;21(3):382-90. doi: 10.1080/10803548.2015.1073431.
Accidents caused by human error are prominent in the medical field. The present study identified medical errors in the emergency triage area by assessing the tasks of all healthcare workers employed in the triage area of an educational hospital in Tehran, Iran in 2014. Data were collected using the systematic human error reduction and prediction approach (SHERPA). The tasks and sub-tasks were determined and analyzed using hierarchical analysis and the errors were extracted. A total of 199 human errors were identified in the different tasks. The rate of error for action was 46.8%, checking was 25.6%, retrieval was 8.5%, communication was 12.1% and selection was 7%. Rate of unacceptable and unfavorable risks were 21.1% and 38.6%, respectively. SHERPA was shown to be an appropriate technique for detecting medical errors. The establishment of control programs should be a high priority in the management and implementation of health facilities in triage areas.
人为失误导致的事故在医疗领域很突出。本研究于2014年通过评估伊朗德黑兰一家教学医院分诊区所有医护人员的任务，识别了急诊分诊区的医疗差错。使用系统人为失误减少与预测方法（SHERPA）收集数据。通过层次分析确定并分析任务和子任务，提取差错。在不同任务中共识别出199起人为失误。行动的差错率为46.8%，检查为25.6%，检索为8.5%，沟通为12.1%，选择为7%。不可接受和不利风险的发生率分别为21.1%和38.6%。结果表明，SHERPA是检测医疗差错的一种合适技术。在分诊区卫生设施的管理和实施中，建立控制程序应是高度优先事项。
