Identification, Assessment, and Control of Errors in Chemotherapy Process: A Case Study between Physician and Nurse

Abstract

Human errors are considered as one of the main causes of incidents in the field of health care.it is very important to predict errors and identify the factors causing them. Chemotherapy ward is considered as one of the most dangerous working environment, where errors can cause severe damages in patients, psychological trauma in the service-provider cadre, declining credit and legal consequences. Since there is no study in this regard and according to the high number of chemotherapists in Iran, the present study was performed to identify and assess physician and nurse’errors during chemotherapy process, and to determine the corresponding risk and safety principles. A cross-sectional descriptive study was conducted in chemotherapy ward at Imam Reza hospital in Kermanshah. Different activities were carried out in this study, including: review literature, examining statistics and scientific resources, interviewing with physicians and nurses in chemotherapy, training the aim and research methodology, studying the instructions of chemotherapy, and monitoring activities and measures. Tasks were analyzed by (HTA) method, then errors were identified by SHERPA instruction, and their risks were evaluated, finally, appropriate control measures were presented to reduce the risks of errors. A total of 459 errors were identified among the 122 task, 10.46 percent of errors were unacceptable, and 42.11 percent were undesirable. Most of the errors were functional, and the fewest were retrieval. These errors occurred for some reasons including: lack of doctors and nurses in relation to the large number of patients, lack of comprehensive guidelines, lack of cooperation between doctors, lack of proper training. According to the results and assessment of obtained risks, functional errors should be prioritized to control and reduce errors, which is possible through the development of guidelines and training courses, the careful monitoring of supervisors and frequent checkup, registering errors and disclosing.

Keywords

• SHERPA
• human‌ errors
• risk assessment
• the physicians and nurses of chemotherapy