Procedure for the analysis and prevention of medication errors using the ergonomics approach
DOI:
https://doi.org/10.17533/udea.rfnsp.e346223Keywords:
human factors and ergonomics, medication errors, wrong procedure errors, patient safety, medication systemAbstract
Medication errors represent a public health problem that affects patient’s safety and the quality of health services on a global scale. This article presents a procedure for the analysis and prevention of medication errors from an ergonomics perspective, exemplifying its application through an illustrative case study of the administration of an injectable
medication. As part of this procedure, hierarchical task analysis (HTA) methods for analyzing the task and, systematic human error reduction, and the prediction approach (SHERPA) for identifying error modes were included. A Risk matrix proposed
in ISO 45001 was used for risk assessment. The proposed procedure consisted of four stages: 1) selection of the task under study, 2) detailed analysis of the task, 3) prediction of the possibility of error, and 4) development of strategies for error reduction. It is expected that the systematic use of this procedure will contribute to improving health service quality, reducing human errors and possible adverse events.
Downloads
References
Sarter DDW, Sidney D, Richard C, et al. Behind Human Error. London: crc Press; 2010.
Senders JW, Moray NP. Human error: Cause, prediction, and reduction. Hillsdale, NJ: Lawrence Erlbaum Associates; 1991.
Reason J. Human error. New York, usa: Cambridge University Press; 1990.
Reason J. Human error: Models and management. bmj. 2000;320(7237):768-70. https://doi.org/10.1136/bmj.320.7237.768
Reason J. Understanding adverse events: human factors. Quality in Health Care. 1995;4(2),80-89. doi: https://doi.org/10.1136/qshc.4.2.80
Anderson JG, Abrahamson K. Your health care may kill you: Medical errors. Stud Health Technol Inform. 2017;234:13-7. doi: https://doi.org/10.3233/978-1-61499-742-9-13
Risk Analytica. The case for investing in patient safety in Canada [internet]; 2017 [citado 2019 nov. 15]. Disponible en: https://bit.ly/Canadian_Patient_Safety
World Health Organization (who). Patient Safety: Data and Statistics [internet]; 2019 [citado 2019 may. 24]. Disponible en: http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics
Donaldson L. An organisation with a memory. Clin Med (Lond). 2002;2(5):452-7. doi: https://doi.org/10.7861/clinmedicine.2-5-452
Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Appl Ergon. 2006;37(5):669-79. doi: https://doi.org/10.1016/j.apergo.2005.08.001
Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet. 2000;355(9208):947-8. doi: https://doi.org/10.1016/s0140-6736(00)99025-1
Aranaz-Andrés JM, Aibar-Remón C, Limón-Ramírez R, et al. Prevalence of adverse events in the hospitals of five Latin American countries: Results of the ‘Iberoamerican study of adverse events’ (ibeas). bmj Quality & Safety. 2011;20(12):1043-51.
Machado-Alba JE, Moncada JC, Moreno-Gutiérrez PA. Errores de medicación en pacientes atendidos en servicios ambulatorios de Colombia, 2005-2013. Biomédica. 2016;36(2):251-7. doi: https://doi.org/10.7705/biomedica.v36i2.2693
Moscoso S, Parra C, et al. Prevención de errores de medicación en la dispensación de medicamentos a pacientes ambulatorios, Colombia junio 2014-junio 2015. Vitae. 2015;22(Supl. 1):S94-S96.
Machado-Alba JE, Moreno-Gutiérrez PA, Moncada-Escobar JC. Hospital medication errors in a pharmacovigilance system in Colombia. Farm Hosp. 2015;39(6):338-49. doi: https://doi.org/10.7399/fh.2015.39.6.8899
World Health Organization (who). Medication without harm-who Global Patient Safety Challenge. Geneva: World Health Organization; 2017.
Holden RJ, Carayon P, Gurses AP, et al. seips 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11):1669-86. doi: https://doi.org/10.1080/00140139.2013.838643
Hignett S, Carayon P, et al. State of science: Human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491-503. doi: https://doi.org/10.1080/00140139.2013.822932
National Health Service (nhs). Developing a patient safety strategy for the National Health Service. Proposals for consultation. London: nhs Improvement; 2018.
ISoP, editor Programm of the ISoP 2019: “New opportunities for new generations”. 19th Annual Meeting of the International Society of Pharmacovigilance; 26th to 29th October; Bogotá, Colombia: Asociación Colombiana de Farmacovigilancia; 2019.
Torres Y, Nadeau S, Landau K. Application of human errors analysis in manufacturing: A proposed intervention framework and techniques selection. Kongress der Gesellschaft für Arbeitswissenschaft [Congress of the German Society of Ergonomics]; feb. 27-mar. 1; Dresden, Germany: GfA-Press; 2019.
Sharit J. Human error and human reliability analysis. In: Salvendy G, editor, Handbook of human factors and ergonomics, Fourth edition. New Jersey, usa: John Wiley & Sons, Inc.; 2012.
Babu VR. 4 - Motion economy. In: Babu VR, editor. Industrial engineering in apparel production. New Delhi, India: Woodhead publishing India; 2012. pp. 47-62.
Stanton NA. Hierarchical task analysis: Developments, applications, and extensions. Appl Ergon. 2006;37(1):55-79. doi: https://doi.org/10.1016/j.apergo.2005.06.003
Anett J. Hierarchical task analysis. In: Hollnagel E, editor. Handbook of cognitive task design. Mahwah, nj: Lawrence Erlbaum Associates; 2003. pp. 17-35.
Kirwan B. Human error identification in human reliability assessment. Part 1: Overview of approaches. Applied Ergonomics. 1992;23(5):299-318. doi: https://doi.org/10.1016/0003-6870(92)90292-4
Khandan M, Yusefi S, et al. sherpa technique as an approach to healthcare error management and patient safety improvement: A case study among nurses. Health Scope. 2017;6(2):e37463. doi: https://doi.org/10.5812/jhealthscope.37463
Embrey DE. sherpa: A systematic human error reduction and prediction approach. Proceedings of the International Topical Meeting on Advances in Human Factors in Nuclear Power Systems, April 21-24; Knoxville, tn: American Nuclear Society; 1986. pp. 184-93.
Embrey D. Application of sherpa to predict and prevent use error in medical devices. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care. 2014;3(1):246-53.
Embrey D, editor sherpa: A systematic human error reduction and prediction approach to modelling and assessing human reliability in complex tasks. 22nd European Safety and Reliability annual conference (esrel 2013). Amsterdam: crc Press; 2014.
International Organization for Standardization (iso). iso 45001: 2018 Occupational health and safety management systems — Requirements with guidance for use. Geneva, Switzerland: iso; 2018.
MacLeod IS, Hone GN, Farmilo AJ, editors. The hta tool [Hierarchical Task Analysis]. 2005 The iee and mod hfi dtc Symposium on People and Systems - Who Are We Designing For (Ref No 2005/11078); 2005 16-17 Nov.; 2005.
Carraretto AR, Curi EF, Almeida CED de, Abatti REM. Ampolas de vidro: riscos e benefícios. Rev Bras Anestesiol. 2011;61(4):517-21. DOI: https://doi.org/10.1590/S0034-70942011000400013
Painchart L, Odou P, Bussières JF. Présence de particules associées à la préparation de médicaments provenant d’ampoules de verre : revue de littérature. Ann. Pharm. Fr. 2018;76(1):3-15. DOI: https://doi.org/10.1016/j.pharma.2017.07.002
Chiannilkulchai N, Kejkornkaew S. Safety concerns with glass particle contamination: Improving the standard guidelines for preparing medication injections. Int J Qual Health Care. 2021;33(2). DOI: https://doi.org/10.1093/intqhc/mzab091
Zhang Z, Qi Q. An efficient rfid authentication protocol to enhance patient medication safety using elliptic curve cryptography. J Med Syst. 2014;38(5):47. doi: https://doi.org/10.1007/s10916-014-0047-8
Pourasghar F, Tabrizi JS, Yarifard K. Design and development of a clinical risk management tool using Radio Frequency Identification (rfid). Acta Inform Med. 2016;24(2):111-5. doi: https://doi.org/10.5455/aim.2016.24.111-115
Sharit J. Human error. In: Salvendy G, editor, Handbook of human factors and ergonomics, Third edition, New Jersey, usa: John Wiley & Sons, Inc.; 2006. pp. 708-60.
Michalek C, Carson SL. La implementación de la administración de medicamentos con código de barras y las bombas de infusión inteligentes es sólo el comienzo del camino seguro para prevenir los errores de administración. Farm Hosp. [internet]. 2020 {citado 2020 jul. 4]; 44(3):114-21. https://scielo.isciii.es/scielo.php?pid=S1130-63432020000300008&script=sci_arttext&tlng=es
Thuemmler C. The Case for Health 4.0. In: Thuemmler C, Bai C, editors. Health 40: How virtualization and big data are revolutionizing healthcare. Cham: Springer International Publishing; 2017. pp 1-22.
Manogaran G, Thota C, et al. Big data security intelligence for Healthcare Industry 4.0. In: Thames L, Schaefer D, editors. Cybersecurity for industry 40: Analysis for design and manufacturing. Cham: Springer International Publishing; 2017. pp. 103-26.
World Health Organization (who). Patient safety curriculum guide: Multi-professional edition. Geneva: who [internet]; 2011[citado 2020 jul. 4]. Diponible en: https://bit.ly/3feRcnf
Yumang-Ross DJ, Burns C. Shift work and employee fatigue: Implications for occupational health nursing. Workplace Health Saf. 2014;62(6):256-61. doi: https://doi.org/10.1177/216507991406200606
Jehan S, Zizi F, Pandi-Perumal SR, et al. Shift work and sleep: Medical implications and management. Sleep Med Disord. 2017;1(2):00008.
Williamson A, Lombardi DA, Folkard S, et al. The link between fatigue and safety. Accid Anal Prev. 2011;43(2):498-515. doi: https://doi.org/10.1016/j.aap.2009.11.011
Kaliyaperumal D, Elango Y, et al. Effects of sleep deprivation on the cognitive performance of nurses working in shift. J Clin Diagn Res. 2017;11(8):CC01-CC3. doi: https://doi.org/10.7860/JCDR/2017/26029.10324
Tannenbaum SI, Traylor AM, et al. Managing teamwork in the face of pandemic: Evidence-based tips. bmj Qual Saf. 2020;30(1):59-63. doi: http://dx.doi.org/10.1136/bmjqs-2020-011447
Garden AL, Le Fevre DM, et al. Debriefing after simulation–based non–technical skill training in healthcare: A systematic review of effective practice. Anaesth Intensive Care. 2015;43(3):300-8. doi: https://doi.org/10.1177/0310057X1504300303
Rasmussen J. Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models. ieee Transactions on Systems, Man, and Cybernetics. 1983;smc-13(3):257-66. doi: https://doi.org/10.1109/TSMC.1983.6313160
Downloads
Published
Versions
- 2022-05-19 (2)
- 2022-03-07 (1)
How to Cite
License
Copyright (c) 2022 Universidad de Antioquia
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The contents of the articles are the responsibility of the authors
The editorial committee has editorial independence from the National School of Public Health "Héctor Abad Gómez" of the University of Antioquia.
The editorial committee is not responsible for aspects related to copying, plagiarism or fraud that may appear in the articles published in it.
When you are going to reproduce and disclose photographs or personal data in printed or digital format, informed consent is required. Therefore, this requirement is required of the author at the time of receipt of the manuscript.
Authors are responsible for obtaining the necessary permissions to reproduce any material protected by reproduction rights.
The authors preserve the moral rights and assign the economic rights that will correspond to the University of Antioquia, to publish it, distribute electronic copies, include them in indexing services, directories or national and international databases in Open Access, under the Creative Commons Attribution license -Not Commercial-Share Equal 4.0 International Commercial (CC BY-NC-SA) which allows others to distribute, remix, retouch, and create from the work in a non-commercial way, as long as the respective credit and license are granted. new creations under the same conditions.
The authors will sign the declaration of transfer of economic rights to the University of Antioquia, after the acceptance of the manuscript.
The editorial committee reserves the right to reject the articles whose authors do not offer satisfactory explanations about the contribution of each author, to meet the criteria of authorship in the submission letter. All authors must meet the four criteria of authorship according to ICMJE: "a) .- That there is a substantial contribution to the conception or design of the article or to the acquisition, analysis or interpretation of the data. b) That they have participated in the design of the research work or in the critical review of its intellectual content. c) .- That has been intervened in the approval of the final version that will be published.d). That they have the capacity to respond to all aspects of the article in order to ensure that issues related to the accuracy or integrity of any part of the work are adequately investigated and resolved. "
-- 
--
