Journal of Ergonomics
مجله ارگونومی
Iran J Ergon
Medical Sciences
http://journal.iehfs.ir
1
admin
1735-1960
2345-5365
8
10.30699/jergon
14
13
fa
jalali
1393
12
1
gregorian
2015
3
1
2
4
online
1
fulltext
fa
ارزیابی خطاهای انسانی در فرایند جراحی آب مروارید چشم با استفاده از تکنیک SHERPA
Evaluating human errors in cataract surgery using the SHERPA technique
سایر موارد
Other Cases
پژوهشي
Research
<p class="MsoNormal" dir="rtl" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217) direction: rtl unicode-bidi: embed"><b><span lang="FA">مقدمه: </span></b><span lang="FA">خطاهای انسانی علت بسیاری از حوادث ناگوار
در مشاغل پزشکی است که سالانه موجب میشود بیماران زیادی جان خود را از دست دهند. با
توجه به بالا بودن آمار انجام عمل جراحی کاتاراکت چشم در ایران و حساسیت بالای آن،
این پژوهش با هدف شناسایی و ارزیابی خطاهای انسانی در طول این عمل انجام شد. </span></p>
<p class="MsoNormal" dir="rtl" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217) direction: rtl unicode-bidi: embed"><b><span lang="FA">مواد و روش ها:</span></b><span lang="FA"> این پژوهش از نوع کیفی بوده و بهصورت مقطعی
برای ارزیابی و شناسایی خطاهای انسانی در فرایند عمل جراحی آب مراورید چشم با استفاده
از تکنیک </span><span dir="ltr" style="font-size: 10pt">SHERPA</span><span dir="rtl"></span><span dir="rtl"></span><span><span dir="rtl"></span><span dir="rtl"></span> <span lang="FA">انجام شد. در این مطالعه
ابتدا با استفاده از روش تحلیل سلسله مراتبی وظیفه، فرایند عمل آب مروارید به وظایف
و زیر وظایف خود تقسیم شد. در مرحله بعد با استفاده از تکنیک انواع خطاها شناسایی ریسک
آنها ارزیابی شد. در پایان راهکارهای کنترلی مناسب برای کاهش ریسک خطاها ارائه شد.</span></span></p>
<p class="MsoNormal" dir="rtl" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217) direction: rtl unicode-bidi: embed"><b><span lang="FA">یافته ها:</span></b><span lang="FA"> <span style="color: black">در مجموع 53 خطا
برای 14 وظیفه در فرایند جراحی شناسایی شد. بیشترین درصد خطاها از نوع عملکردی و کمترین
درصد خطاها از نوع بازیابی بودند. ریسک 22/64%خطاهای شناسایی شده از نوع نامطلوب بود</span>.</span></p><p class="MsoNormal" dir="rtl" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217) direction: rtl unicode-bidi: embed"><b><span lang="FA" style="font-size: 10pt line-height: 107%">نتیجه</span></b><span dir="ltr"></span><span dir="ltr"></span><b><span lang="FA" dir="ltr" style="font-size: 10pt line-height: 107%"><span dir="ltr"></span><span dir="ltr"></span>
</span></b><b><span lang="FA" style="font-size: 10pt line-height: 107%">گیری</span></b><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 10pt line-height: 107%"><span dir="ltr"></span><span dir="ltr"></span>: </span></b><span lang="AR-SA" style="font-size: 10pt line-height: 107%">با توجه بهشدت پیامدهای ناشی از خطاهای انسانی در عمل
آب مروارید، کاهش نرخ خطاهای شناسایی شده بسیار ضروری است. با توجه به نوع و
فراوانی خطاهای شناسایی شده، یافتههای مطالعه بر طراحی و اجرای دورههای آموزشی
ایمنی مبتنی بر رفتار برای چشمپزشکان تاکید میکند</span></p><br><span lang="AR-SA"></span><p></p>
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<p class="MsoNormal" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217)"><b><span>Introduction:</span></b><span> Human errors
result in numerous accidents in healthcare professions every year and lead to
the death of many patients. Considering the high rate of eye cataract surgeries
performed in Iran and the sensitive nature of the surgery, the present study
was conducted to identify and assess possible human errors in the performance
of these surgeries. </span></p>
<p class="MsoNormal" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217)"><b><span>Materials and
Methods:</span></b><span> The present qualitative, cross-sectional study was conducted to identify
and assess human errors in the process of eye cataract surgery using the SHERPA
technique. At first, using the hierarchical task analysis method,
the surgery process was divided into tasks and sub-tasks. In the next step,
through the same technique, possible human errors were detected and
risk-assessed. Appropriate prevention solutions were then proposed for reducing
the risk of errors.</span></p>
<p class="MsoNormal" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217)"><b><span>Results:</span></b><span> A total of 53
possible errors were detected for the 41 tasks in the surgery process. The
highest error percentages pertained to performance and the lowest pertained to
retrieval. Moreover, the risk of 22.64% of the errors detected was deemed
unacceptable. </span></p>
<p class="MsoNormal" style="margin-bottom: 0.0001pt text-align: justify line-height: normal background: none repeat scroll 0% 0% rgb(217, 217, 217)"><b><span>Conclusions:</span></b><span> Given the
severity of the outcomes of human errors in cataract surgery, reducing the rate
of the detected errors is crucial. According to the type and frequency of the
detected errors, the findings of the present study emphasize the importance of
designing and implementing behavior-based safety training programs for
ophthalmologists. </span></p>
خطای انسانی, SHERPA, آب مروارید
Human error, SHERPA, Cataract.
41
47
http://journal.iehfs.ir/browse.php?a_code=A-10-120-2&slc_lang=fa&sid=1
Iraj
Mohammadfam
ایرج
محمدفام
10031947532846002391
10031947532846002391
No
دانشگاه علوم پزشکی همدان
Chiman
Saeidi
چیمن
سعیدی
chiman_hse2012@yahoo.com
10031947532846002392
10031947532846002392
Yes
MS Student, Department of Occupational Health, Faculty of Health, Hamadan University of Medical Sciences, Iran
دانشجوی کارشناسی ارشد، گروه مهندسی بهداشت حرفهای، دانشکده بهداشت، دانشگاه علوم پزشکی همدان