Mehran Pourhossein, Reza Pourbabaki, Elahe Roudi, Vahid Ahmadi Moshiran, Homa Maleck Khani, Samane Khodaverdloo,
Volume 10, Issue 4 (11-2020)
Abstract
Introduction: Errors are a byproduct of human information processing or cognitive functioning. Although everyone is disposed to an error while performing various activities, individual differences in cognitive abilities can lead to various types and rates of errors committed in similar situations. Human errors are one of the most important challenges in work environments, including health care systems, wherein such errors are abundantly occurring. Errors in the delivery of correct medications due to the resemblance in appearance and name are thus one of the cognitive errors that come about in health care systems. The main purpose of this systematic review was to evaluate evidence and approaches recently practiced to reduce medication errors caused by the use of look-alike-sound-alike (LASA) medications.
Material and Methods: The study was conducted on August 30, 2018, through searches in the databases of PubMed and Embase, all available years, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) instructions. The searches were done in the titles or abstracts of the articles using the intended terms and the Medical Subject Headings (MeSH) index in combination. These studies were selected based on the inclusion and exclusion criteria and then categorized based on the type of interventions and outputs. Finally, the data were analyzed descriptively.
Results: The research designs and methods varied widely among the studies. There were also discrepancies in the number of participants, number of tests, type of medications, and test conditions. The approaches examined in these studies were tall-man lettering, color-coding, label background variations, and use of signs and symbols. Accordingly, 11 studies had utilized tall-man lettering and the most important reported in all articles were “error rate” and “response times”. As well, a wide range of medication names had been tested. It should be noted that medication
Conclusion: errors have different dimensions, but the errors caused by the look-alike-sound-alike (LASA) medications and the effect of tall-man lettering of medication name were only investigated in the present study. Laboratory studies in this respect have shown that tall-man lettering contributes to mitigating the rate of errors, which might be due to the better legibility of labels, but evaluations in real work environments are needed to reinforce this conclusion. There is also insufficient evidence to support color-coding, as well as several other approaches such as use of signs and symbols. Because of the novelty of the studies in this field, no uniform mechanism has been so far introduced.
Gholam Abbas Shirali, Davood Afshari, Sanaz Karimpour,
Volume 11, Issue 2 (6-2021)
Abstract
Introduction: Considering the accreditation of international standards of hospitals and the necessity to improve the safety and quality of patients’ care, this study aimed at evaluating reliability among nurses using predictive analysis of cognitive errors and human event analysis techniques.
Material and Methods: The analysis of nurses̓ tasks was done by HTA method. Then, the types of errors and their causes were identified by TRACER method. In the next step, the error probability of each task was calculated by ATHEANA method. In order to calculate the probability of total event, the probability of human error was imported to probabilistic risk assessment.
Results: Factors affecting performance of the nurses were included: the complexity of the work, high workload, nurse’s experience, work environment design, fatigue, anxiety, shortage of the workforce, insufficient time period for doing job, sleep disturbance, and poor lighting and noise pollution. According to the instruction of ATHEANA method, the error probability for each base event was considered 0.001. Given that there are 15 base events, the probability of human error in the heart attack event was calculated 0.015.
Conclusion: The finding of this study was indicated the need for providing required nursing workforce, reducing overtime, scientific planning for nurses’ work shifts and giving practical training and stress management methods in the emergency conditions.
