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

Human errors are considered as one of the main causes of incidents in the field of healthcare. It is very important to predict errors and identify the factors causing them. 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. This cross-sectional descriptive study was conducted in chemotherapy ward at Imam Reza hospital in Kermanshah, Iran, in 2015. Different activities were carried out 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. Overall, 459 errors were identified among the 122 task, 10.46% of errors were unacceptable, and 42.11% 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 a large number of patients, lack of comprehensive guidelines, lack of cooperation between doctors, lack of proper training. Functional errors should be prioritized to control and reduce errors, which are possible through the development of guidelines and training courses, the careful monitoring of supervisors and frequent checkup, registering errors and disclosing.