Chemical Engineering Department, Instituto Superior de Engenharia de Lisboa (ISEL), Lisbon, Portugal.
Mechanical Engineering Department, Instituto Superior de Engenharia de Lisboa (ISEL), Lisbon, Portugal.
Int J Risk Saf Med. 2022;33(3):287-298. doi: 10.3233/JRS-210019.
Human error has been studied for large decades with special application to critical infrastructures and processes where the impact of such errors can induce severe or catastrophic consequences. In this sense it is of utmost importance to extend this type of analysis to other fields as medicine.
This study proposes a semi-quantitative human error risk assessment methodology, including the analysis of the so-called Performance Shaping Factors (PSFs), in order to contribute to health services improvement.
A questionnaire including the considered PSFs is answered in order to determine the impact of each PSF and its influence on human error. It allows performing a Human Error Risk Assessment (HERA) for both the patient (HERAp) and the quality of the service (HERAq).
The results show the PSFs with the highest impact factor. After applying corrective measures, it is possible to observe the impact on the reduction of the risk for patient and for the quality of the service.
The application of the methodology with the inclusion of the impact of PSFs allows minimizing or mitigating failure modes with greater risk as well as increasing patient safety and promoting a better quality of medical procedures.
人为错误已经被研究了几十年，特别是应用于关键基础设施和过程，这些错误的影响可能会导致严重或灾难性的后果。在这个意义上，将这种类型的分析扩展到其他领域，如医学，是非常重要的。
本研究提出了一种半定量的人为错误风险评估方法，包括对所谓的绩效形成因素（PSFs）的分析，以有助于改善卫生服务。
回答一份包括所考虑的 PSFs 的问卷，以确定每个 PSF 的影响及其对人为错误的影响。它允许对患者（HERAp）和服务质量（HERAq）进行人为错误风险评估（HERA）。
结果显示了影响因素最高的 PSFs。在应用纠正措施后，可以观察到对降低患者风险和服务质量的影响。
通过应用包括 PSFs 影响的方法，可以最小化或减轻风险较大的失效模式，同时提高患者安全性并促进医疗程序的质量提高。
