Original Article

Identification of Nurses’ Errors in the Emergency Ward, Using SHERPA Technique

Abstract

Introduction: Human errors are of the most important issues due to the technological advances in various work settings. In medical professions, including nursing, investigation of human errors would help to find out approaches for the identification and reduction of these errors. Hence, the present study aimed to identify and assess nurses' errors in emergency ward of an educational hospital, using Systematic Human Error Reduction and Prediction Approach (SHERPA).
Method: In this qualitative study, first, the purpose and the procedure of the research were completely explained to the nurses. Then, Hierarchical task analysis (HTA) was done and the nurses' tasks and subtasks were identified by observing their activities and conducting interviews. Then, the SHERPA worksheet was completed to find the errors pertinent to each task.
Discussion: Sixty-five tasks and 231 errors were detected regarding the nurse's tasks, of which 59.3% was action errors, 25.55% checking errors, 4.33% retrieval errors, 2.16% information communication errors, and 8.66% selection errors. This means that the highest and lowest errors were respectively belonged to action errors and communication errors. Moreover, the checking errors obtained the highest undesirable risk level.
Result: Overall, the action errors and the checking errors should be priority in controlling and reducing of nurses errors in emergency ward. It should be noted that SHERPA can cover a wide range of activities including factors such as patients and their caregivers or other wards of the hospitals which make this technique an appropriate tool for assessing the errors in medical professions. 

Reason J. Human error: models and management. BMJ 2000; 320(7237): 768–770.

Karwowski W. International encyclopedia of ergonomics and human factors. CRC Press, 2001.

Feyer A, Williamson A. Human factors in accident modelling. In: Stellman J(Ed). Encyclopaedia of occupational health and safety. 4th edn. International Labour Organization, 1998.

Kermani A, Mazloumi A, Kazemi Z. Using SHERPA technique to analyze errors of health care staff working in emergency ward of Amiralmomenin hospital, Semnan. Iran Occup Health 2015; 12(2): 12-23.

WHO. World Alliance for Patient Safety. The Launch of the World Alliance for Patient Safety. Oct 2004.

Dhingra KR, Elms A, Hobgood C. Reducing error in the emergency department: a call for standardization of the sign-out process. Ann Emerg Med 2010; 56(6): 637-642.

Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Appl Ergon 2006; 37(5): 669-679.

The National Academy of Science. Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually. Jul 2006.

Fontan J-E, Maneglier V, Nguyen VX, Brion F, Loirat C. Medication errors in hospital: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci 2003; 25(3): 112-117.

Ivy ME, Cohn K. Human error in hospitals and industrial accidents. JACS 2001; 192(3): 421.

Baker GR, Norton PG, Flintoft V, Blais Rg, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170(11): 1678-1686.

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): 228-231.

Ghanbari Jahromi M, Khammarnia M, Haghayghi F, Eslahi M, Saeed A, Kassani A. The Medical Errors and Causes in the General Public Hospital, Southern Iran. Med Public Health J 2014; 1(3): 10-14.

Mohammadfam I, Movafagh M, Bashirian S. Comparison of Standardized Plant Analysis Risk Human Reliability Analysis (SPAR-H) and Cognitive Reliability Error Analysis Methods (CREAM) in Quantifying Human Error in Nursing Practice. Iran J Public Health 2016; 45(3): 401-402.

Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon 2009; 40(3): 379-395.

Stanton NA, Walker GH. Human factors methods: a practical guide for engineering and design. 2nd ed, Ashgate Publishing, Lt, 2013.

Bahr NJ. System safety engineering and risk assessment: a practical approach. CRC Press, 2014.

Simpleman L, McMahon P, Bahnmaier B, Evans K, Lloyd J. Risk management guide for DOD acquisition. Department of Defense Acquisition University, June 2003.

Phipps D, Meakin GH, Beatty PCW, Nsoedo C, Parker D. Human factors in anaesthetic practice: insights from a task analysis. Br J Anaesth 2008; 100(3): 333-343.

Ghasemi M, Zakerian A, Azhdari M. Control of Human Error and comparison Level risk after correction action With the SHERPA Method in a control Room of petrochemical industry. Iran Occup Health 2011; 8(3): 14-22.

Habibi E, Garbe G, Reasmanjeyan M, Hasanzadah E. Human error assessment and management in Isfahan oil refinery work station operators by Sherpa technique. Inj Prev 2012; 18: A229.

Tanha F, Mazloumi A, Faraji V, Kazemi Z, Shoghi M. Evaluation of human errors, using Standardized Plant Analysis Risk Human Reliability Analysis technique, among nurses of delivery emergency ward of one of the Tehran University of Medical Sciences hospitals. J Hosp 2015; 14(3): 57-66.

Kazaoka T, Ohtsuka K, Ueno K, Mori M. Why nurses make medication errors: a simulation study. Nurse Educ Today 2007; 27(4): 312-317.

Seki Y, Yamazaki Y. Effects of working conditions on intravenous medication errors in a Japanese hospital. J Nurs Manag 2006; 14(2): 128-39.

Plews-Ogan ML, Nadkarni MM, Forren S, Leon D, White D, Marineau D, et al. Patient safety in the ambulatory setting. J Gen Intern Med 2004; 19(7)719-725.

Furukawa H, Bunko H, Tsuchiya F, Miyamoto K-i. Voluntary medication error reporting program in a Japanese national university hospital. Ann Pharmacother 2003; 37(11): 1716-1722.

Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med 2006; 3(12): e487.

Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168(12): 616-618.

Gawande A. The checklist. N Y 2007; 83(39): 86-95.

Files
IssueVol 8 No 1 (2016) QRcode
SectionOriginal Article(s)
Published2016-03-24
Keywords
Human Error Identification SHERPA Risk Assessment Nursing Emergency Ward

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
KERMANI A, MAZLOUMI A, KAZEMI Z. Identification of Nurses’ Errors in the Emergency Ward, Using SHERPA Technique. Int J Occup Hyg. 2016;8(1):54-61.