Dr Zahra Kavosi, Fateme Setoodehzadeh, Mozhgan Fardid, Maryam Gholami, Marzie Khojastefar, Mahbube Hatam, Zahra Tahiati, Gholamreza Fardid,
Volume 16, Issue 3 (11-2017)
Background: Reduction of errors is necessary to improve the quality of healthcare, promoting communication between the hospital staff and patients, and decreasing the patient's complaints in hospitals. Due to the high probability of error in the operating room (OR), this study aimed to detect the potential errors in the OR of Nemazee hospital using FMEA.
Materials and Methods: This study was a qualitative one which assessed Failure Mode and effects of OR in six steps using FMEA technique. At First, the OR activities were listed, then the failure modes were recognized. Next, the Risk Priority Number (RPN) of each error was calculated according to the indicators of Occurrence (O), Severity (S) and Detectability (D).
Results: Totally,204 failure modes in 36 activities in five process in surgery ward were recognized.15.7 percent of failure modes classified as high risk factors (RPN ≥ 100). The most and the least distribution of origin factors were related to human and organization and technical errors, respectively.
Conclusion: The majority of errors in OR was set in of human skills category. Besides, the most and the least failure modes were belonged to “patient anesthesia by circular activity number 20, RPN=1795.23)” and “not to oxygenation for patients (the activity number 36, RPN=99.33) respectively. Identification of 36 activities and 204 errors in the 5 processes of Operating Room represents the comprehensiveness of HFMEA method in the identification, classification, evaluation and analysis of the health system errors.
