ارزیابی قابلیت اطمینان انسانی در فرآیند عمل جراحی آپاندکتومی با استفاده از روش استاندارد واکاوی ریسک خطای انسانی (Spar-H)

مقدمه: پیامدهای جبران‌ناپذیر خطای انسانی در بخش بهداشت و درمان، ایمنی بیماری را به یک اصل با اهمیت در مشاغل پزشکی تبدیل کرده است. هدف از مطالعه حاضر بررسی احتمال خطای انسانی در پرسنل اتاق عمل در فرآیند عمل جراحی آپاندکتومی بود.روش بررسی: این مطالعه مقطعی و توصیفی جهت شناسایی و ارزیابی احتمال خطای انسانی در وظایف پرسنل اتاق عمل در فرآیند عمل جراحی آپاندکتومی در بیمارستان شهید صدوقی یزد صورت گرفت. در ابتدا با مصاحبه با پرسنل و مطالعه روند و رویه‌های انجام کار، وظایف شغلی پرسنل با استفاده از روش تحلیل سلسله مراتبی وظایف (hta) مورد واکاوی قرارگرفته‌اند. در نهایت احتمال خطا با استفاده از روش sparh برای وظایف متفاوت محاسبه شد.نتایج: احتمال خطای انسانی میانگین برای کل وظایف برابر 0.173 بود. همچنین بیشترین میانگین احتمال خطا مربوط به وظایف متخصص بیهوشی (0.23) و کمترین مربوط به وظایف اسکراب (0.101) بوده است.نتیجه‌گیری: بیشتر بودن احتمال رخداد خطا در وظیفه تکرار داروهای بیهوشی نسبت به بقیه وظایف می‌تواند نشانگر تاثیر زیاد فرآیندهای شناختی در رخداد خطا باشد. جهت کاهش احتمال خطای انسانی می‌توان کاهش وابستگی را از طریق انجام وظایف توسط افراد متفاوت و در صورت امکان با فاصله زمانی از هم انجام داد. همچنین استرس، پیچیدگی و رویه‌های کاری به‌عنوان مهم‌ترین عوامل موثر بر قابلیت اطمینان انسانی شناخته شدند.

Assessment of the probability of human error occurring in the process of appendectomy operation using SPAR-H method

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Assessment of the probability of human error occurring in the process of appendectomy operation using SPARH method Taherzadeh Chenani KH1, Jahangiri M 2, Jafari Nodoushan R *3, Madadizadeh F 4, Fallah H5,6 1 Department of Occupational Health Engineering, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran2 Department of Occupational Health Engineering, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran3 Department of Occupational Health Engineering, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran4 Research Center of Prevention and Epidemiology of NonCommunicable Disease, Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran5 Department of Occupational Health Engineering, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran6 Occupational Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran AbstractIntroduction: The irreparable consequences of human error in the health care sector have made patient safety an important principle in medical professions. The aim of the present study was to investigate the probability of human error in operating room personnel in the process of appendectomy operations.Materials and Methods: This crosssectional and descriptive study was performed to identify and evaluate the probability of human error in operating room personnelchr('39')s tasks in the process of appendectomy in Shahid Sadoughi Hospital in Yazd. Initially, by interviewing personnel and studying the process and procedures of the work, the job duties of the personnel were analyzed using HTA method. Finally, the probability of error was calculated using SPARH method for different tasks.Results: The average human error probability for all tasks was 0.173. Also, the highest mean of error was related to anesthesiologist duties (0.23) and the least related to scrub duties (0.101).Conclusion: The SPARH method can be used to analyze and quantify the probability of human error in the operating room. To reduce the likelihood of human error, we can reduce dependency by performing different tasks with different people and if possible with long time between them. Also, stress, complexity and procedures were identified as the most important factors affecting the probability of error.