Volume 19, Issue 5 (August 2021)
Nursing and Midwifery Journal 2021, 19(5): 359-365 |
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Motie M, Rafie S, Kalavani K. IDENTIFICATION AND EVALUATION OF MIDWIFERY STAFF ERRORS IN THE KOSAR TRAINING CENTER BY SHERPA METHOD. Nursing and Midwifery Journal 2021; 19 (5) :359-365
URL: http://unmf.umsu.ac.ir/article-1-4039-en.html
URL: http://unmf.umsu.ac.ir/article-1-4039-en.html
1- 1. MA Student in Nursing, Faculty of Nursing, Islamic Azad University of Tehran, Tehran, Iran
2- 2.Associate Professor of Health Services Management, Faculty of Health, Qazvin University of Medical Sciences, Qazvin, Iran
3- PhD candidate in Health Services Management, Faculty of Healthcare Management, Kerman University of Medical Sciences, Kerman, Iran (Corresponding Author) , k.kalavani@kmu.ac.ir
2- 2.Associate Professor of Health Services Management, Faculty of Health, Qazvin University of Medical Sciences, Qazvin, Iran
3- PhD candidate in Health Services Management, Faculty of Healthcare Management, Kerman University of Medical Sciences, Kerman, Iran (Corresponding Author) , k.kalavani@kmu.ac.ir
Abstract: (2237 Views)
Background & Aims: Midwifery activity is one of the most essential cares in obstetrics and gynecology services, which plays an important role in improving maternal and neonatal health. With increasing global concern about the effects of childbirth and the importance of this process, any human error in this regard is non-negligible. Therefore, given the significant mortality and adverse effects, safe and effective delivery control is a critical issue.
Materials & Methods: This cross-sectional study was performed to identify and evaluate midwifery staff errors of Kowsar Hospital of Qazvin in 2018. There are various ways to identify, evaluate, and predict human errors. Among these, the SHERPA technique is one of the most common methods to detect these errors.
Results: After hierarchical analysis, the main tasks were divided into 68 sub-tasks. Finally, 65 errors were identified for midwifery staff activities )57% action errors, 25% revision errors, 6% retrieval errors, 9% communication errors, and 3% selective errors). Therefore, the highest percentage was the action errors and the least was the selective errors.
Conclusion: Hospital authorities should pay more attention to action errors and prioritize these errors in patient safety. It is recommended that appropriate actions be taken to establish a culture of patient safety.
References
1. Emeis CL, Jolles DR, Perdion K, Collins-Fulea C. The American College of Nurse-Midwives' Benchmarking Project: A Demonstration of Professional Preservation and Improvement. J Perinat Neonatal Nurs 2021 ;35(3):210-20. [DOI:10.1097/JPN.0000000000000576] [PMID]
2. Mirghafourvand M, Hajizadeh K, Kondori J, Kamalifard M, Bazaz Javid Z. Barriers to and facilitators of medication error reporting from the viewpoints of nurses and midwives working in gynecology wards of Tabriz hospitals. J Patient Saf Risk Manag 2021;26(3):104-10. [DOI:10.1177/25160435211009023]
3. Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with a prolonged second stage of labor. Obstet Gynecol 2003; 102(1):52-8.
https://doi.org/10.1016/S0029-7844(03)00400-9 [DOI:10.1097/00006250-200307000-00013]
4. Irani M, Kordi M, Lotfalizadeh M. Methods of Assessing the Labor Progress: A Review Study. Iran J Obstet Gynecol Infertil 2019; 21(11): 80-90. [URL]
5. Darvishi M, Ranjbaran M, Jourabchi Z, Jafarimanesh H. Effect of the presence of midwife and non-midwife companion on labor pain, duration of delivery, and amount of oxytocin drops in primiparous women: a clinical trial study. Iran J Obstet Gynecol Infertil 2019;22(4):63-72. [URL]
6. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain--United States, 2016. JAMA 2016; 315(15):1624-45. [DOI:10.1001/jama.2016.1464] [PMID] [PMCID]
7. Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of 7. Hospital errors. Int J Prod Econ 2007;106(2):368-92. [DOI:10.1016/j.ijpe.2006.07.005]
8. 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. Qual Saf Health Care 2003;12(6):443-7. [DOI:10.1136/qhc.12.6.443] [PMID] [PMCID]
9. Santamaría J, Brana P. Risk analysis and reduction in the chemical process industry. Blackie Academic and Professional, London; 1998.
10. Mosadeghrad A M, Isfahani P, Yousefinezhadi T. Medical errors in Iranian hospitals: systematic review. Tehran Univ Med J 2020; 78 (4) :239-47. [URL]
11. Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf 2013;22(10):809-15. [DOI:10.1136/bmjqs-2012-001748] [PMID]
12. Pahlevan D, Jandaghi J, Shaeeri M, Razavi M, Abdollahpour A, Kermani A. Classification and assessment of medication errors in the emergency unit of a hospital in Iran by SHERPA. Middle East Journal of Family Medicine 2018 ;7(10):107. [DOI:10.5742/MEWFM.2018.93353]
13. Mohammadfam I, Bashirian S, Bakhshi Z. Evaluation and Management of Human Errors in Critical Processes of Hospital Using the Extended CREAM Technique. Iranian Journal of Health, Safety and Environment 2017 ;4(4):851-8. [DOI:10.5812/jjhs.64062]
14. Al-Zain Z, Althumairi A. Awareness, Attitudes, Practices, and Perceived Barriers to Medical Error Incident Reporting Among Faculty and Health Care Practitioners (HCPs) in a Dental Clinic. J Multidiscip Healthc. 2021;14:735. [DOI:10.2147/JMDH.S297965] [PMID] [PMCID]
15. Parry AM, Barriball KL, While AE. Factors contributing to registered nurse medication administration error: a narrative review. Int J Nurs Stud 2015;52(1):403 [DOI:10.1016/j.ijnurstu.2014.07.003] [PMID]
16. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 [cited 2021 Aug 31]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK499956/. [Pubmed]
17. MohammadNejad S, Hojjati H, Ehsani R. Evaluation of medication errors in nursing students in four teaching hospitals of Tehran. J Med Ethics Hist Med 2008;88. [URL]
18. Carlton G, Blegen MA. Medication-related errors: a literature review of incidence and antecedents. Annu Rev Nurs Res 2006;24:19-38. [DOI:10.1891/0739-6686.24.1.19] [PMID]
19. Cheragi MA, Manoocheri H, Mohammadnejad E, Ehsani SR. Types and causes of medication errors from nurse's viewpoint. Iran J Nurs Midwifery Res 2013;18(3):228-31. [PMID]
20. Kermani A, Mazloumi A, Naslseraji J, Ghasemzadeh F. Identification and evaluation of human errors using SHERPA method in Emergency Physicians working in Semnan Amiralmomenin Hospital. Occup Med Quart J 2014;5(3): 87-78. [URL]
21. 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 Soc Behav Sci 2013; 84:949-53. [DOI:10.1016/j.sbspro.2013.06.680]
22. Stanton N, Salmon P, Baber C. Human factors design & evaluation methods review Human error identification techniques "SHERPA." 1ed, Alvington 2004;140-8.
23. Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon 2009;40(3):379-95. [DOI:10.1016/j.apergo.2008.11.004] [PMID]
24. Mohammad Fam I. Engineering of safety. Tehran: Fanavaran; 2001.
25. Stoneburner G, Goguen A, Feringa A. Risk management guide for information technology systems. Nist special publication 2002;800(30):800-30. [DOI:10.6028/NIST.SP.800-30]
26. Dastaran S, Hasheinejhad N, Shahravan A, Baneshi M, Faghihi A. Identification 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. [DOI:10.21859/johe-02046]
27. Kermani A, Mazloumi A, NaslSeraji J, GhasemZadeh F. Identification and evaluation of human errors using SHERPA technique among nurses at emergency ward of an educational hospital in Semnan city, Iran. Occup Med Quart J 2013;40(4):29-43. [URL]
28. Kroghdeh J. Identification and Evaluation of Human Errors in Surgery part in Kerman hospital by using SHERPA Method. Kerman: Kerman University of Medical Science; 2013.
29. Bunn J, Berentsen R, Glittum E, Steinsvik LK. A Human Factors Approach to Reduce Hydrocarbon Leakages on the Norwegian Continental Shelf. In: SPE International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. OnePetro; 2010. [DOI:10.2118/126469-MS]
30. Spencer FC. Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000;191(4):410-8. [DOI:10.1016/S1072-7515(00)00691-8]
31. Ghasemi M. Survey of Ergonomic Human Error in Control Room of Petrochemical Industry by SHERPA. Health School of Tehran University of Medical Science; 2009.P.2-150.
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