Original Article

Errors Evaluation Using Barrier Analysis- A Case Study in Laboratory Unit

Abstract

The laboratory unit is one of the most dangerous work environments in which the occurrence of errors can lead to severe injuries to patients, psychological damages to the service providers, degradation of the unit, and legal consequences. This descriptive cross-sectional study was conducted in the laboratory unit of Akhtar Hospital in Tehran. The current study was organized as follow: literature review based on previous studies and scientific resources, interview with laboratory staffs, design the methodology of research, studying the instructions, observing activities and practices. A Hierarchal Task Analyze (HTA) method was applied to evaluate tasks, thereafter errors and obstacles were identified based on Barrier Analysis instruction. Finally appropriate control strategies were proposed to reduce the risk of errors.  A total of 552 errors were identified of which 86 barriers were  in the laboratory unit including 12 administrative barriers, 15 statutory barriers, 9 humanitarian action barriers, 18 supervision and cooperation barriers, 8 educational barriers, 0 natural barriers, 9 physical barriers and Finally 15 environmental design barriers. The results and risk assessment showed that functional errors (maximum frequency) and errors in this area should be given priority to be controlled and reduced. This is possible through the development of instructions, training courses, close supervision on officials and frequent inspections, record the errors and disclosure.

Jahangiri M HN, Rostamabadi A, Keshavarzi S. Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant. Safety and Health at Work. 2016;6(11):6-11.
2. M M. Increasing safety by implementing optimized structures of team communication and the mandatory use of checklists. European Journal of Cardio-Thoracic Surgery. 2012;41:988–92.
3. RL B. Safety and health for engineers. Edition n, editor2006.
4. JN C. Always having to say you are sorry: an ethical response to making mistakes in professional practice. . Nurse Ethics. 2004;11(6):568-76.
5. Johnstone MJ KO. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: A discussion paper. International Journal of Nursing Studies. 2006;43:367–76.
6. World Alliance for Patient Safety. 2008; 09-27. Availible: http://www.who. int/patientsafety /en/index.html [
7. Elfering A SN, Grebner S. Work stress and patient safety:observer-rated work stressors as predictors of characteristics of safetyrelated events reported by young nurses. Ergonomics. 2006;49(5):457-69.
8. Weingart SN WR, Gibberd R, Harrison B. Epidemiology of medical error. BMJ. 2000;172:774-7.
9. Fein S HL, Singer MK, Spiritus E,Keenan C,Seymann G,Sojania K,Wenger N. A Conceptual Model for Disclosure of Medical Errors. Advanced in Patient Safety. 2008;2:483-94.
10. Colledge A CJ, Donnelly A, Majeed A. Health information for patients: time to look beyond patient information leaflets. J R Soc Med. 2008;10(9):447–53.
11. A publication of the University of Texas at Austin. Lab safety Manual 2000. 2. Adl J. Existing hazards and failure in university laboratories. Tehran University Medical Journal 2004; 6(48): 252. [Persian]
12. TK B. Implementing guidelines to improve medication safety for hospitalised patients experiences from Western Health, Australia. Worldviews on Evidence Based Nursing. 2007;4(1):51-3.
13. Rothschild JM HC, Landrigan JW,Cronin K, Martell-Waldrop C,Foskett E, Burdick CA, Czeisler D, Bates W. Recovery from medical errors: The critical care nursing safety net. Joint Commission Journal on Quality & Patient Safety. 2006;32(2):63-72.
14 Shanoofi M1 , Zakerian SA2 , Nikoomaram H. Human Error Protection Layers Analysis for Nursing in CCU Department with Proactive Approach. Journal of Healthcare Management 2018; 8 (4) / 11
15. Karahan A UZ, Kav S,Abbasoglu A, Kural N, Karaer H. Medication Errors in Oncology Clinics – an Analysis of Incident Reports From Nurses. Poster Presentations, European Journal of Oncology Nursing. 2012:S21–S46.
16. Marquard J HP, Junghee Jo Ze, Fisher DL, Henneman E. Nurses’ Behaviors and Visual Scanning Patterns May Reduce Patient Identification Errors. Journal of Experimental Psychology. 2011;17(3).
Files
IssueVol 12 No 3 (2020) QRcode
SectionOriginal Article(s)
Published2020-09-30
Keywords
Barrier Analysis Human Error Laboratory Unit

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Mahroozadeh G, Nikoomaram H, Zakerian SA. Errors Evaluation Using Barrier Analysis- A Case Study in Laboratory Unit. Int J Occup Hyg. 12(3):192-202.