ارزيابي خطاي انساني به روش HEART در مشاغل اتاق هاي عمل بيمارستان امام حسين (ع) شهرستان گلپايگان و ارائه ي راهكارهاي اولويت بندي شده

HEART assessment of human error in the staff of operating rooms in Imam Hussein hospital of Golpayegan and providing prioritizaed solutions

با توجه به اهميت مشاغل درماني و علي الخصوص مشاغل موجود در اتاق عمل در بهبود بيماري ها و همچنين حفظ جان افراد ، بروز خطا و قصور در انجام وظايف كاركنان اين مراكز تبعات جبران ناپذيري خواهد داشت لذا يافته هاي اين مطالعه مي تواند راهنماي مناسبي جهت كاهش خطاهاي كاركنان اتاق عمل باشد. روش بررسي: اين مطالعه به روش HEART جهت بررسي خطاي انساني كاركنان اتاق عمل انجام شد.جهت انجام اين مطالعه ضمن حضور در شيفت هاي مختلف در اتاقهاي عمل و آموزش و توجيه كاركنان اين بخش در خصوص مطالعه و و اهداف آن، مراحل انجام كار كاركنان اتاق عمل در شغل هاي مختلف مشاهده شد و اسناد و دستورالعمل هاي موجود بررسي گرديد.همچنين گام هاي اصلي كه شامل آناليز سلسله مراتبي مشاغل،شناسايي خطاها برحسب هر وظيفه و زير وظيفه،تكميل ساير قسمتهاي برگه كار و تعيين احتمال بروز خطاي انساني و ارايه ي راهكارهاي كنترلي اولويت بندي شده در مراحل بعد انجام شد. نتايج: عامل خستگي با فراواني 164 (11/47%) و سهل انگاري با فراواني 160 (11/2%) بيشترين عوامل بروز خطا در مشاغل اتاق هاي عمل اين بيمارستان شناسايي شدند و محيط كار نامناسب با فراواني 1 (0/0007%)كمترين عامل بروز خطا مي باشد. نتيجه گيري:تجهيز اتاق هاي عمل به تجهيزات پيشرفته، به كارگيري و استخدام نيروهاي ماهر و باتجربه، تنظيم برنامه ي كار و استراحت كاركنان، ارائه ي آموزش هاي متناسب با نيازهاي كاركنان و بهبود سيستم هاي نظارتي و مديريتي مهمترين راهكارهاي بهبود شرايط موجود و كاهش خطاهاي انساني مي باشد.

Introduction: Considering the importance of medical care, especially occupations in the operating room for disease improvement as well as life preservation, the consequences of failure to perform the duties may be irreparable, so this study was performed to provide useful solutions to reduce errors in operating room staff. Methods: This study was performed by HEART method to investigate the human error in the operating room staff. To perform this study, by attending in various shifts in the operating rooms, training and justifying the employees of this department regarding the study and its objectives was done, the staffing. The operating room was observed in various occupations and the existing documents and guidelines were reviewed. Also, the main steps, including hierarchical analysis of occupations, identifying errors in terms of each task and sub-task, completing other parts of the work sheet and determining the probability of human error and providing prioritized control strategies were carried out in the next steps. Results: According to the results, Fatigue factor with frequency of 164 (11.47%) and negligence with frequency of 160 (11.2%) were the most frequent errors in the occupations of operation rooms of this hospital. The inappropriate work environment with frequency of 1 (0.0007%) was the factor with the least import to induce errors. Conclusion: suppling the operating rooms with advanced equipment, employing and recruiting skilled and experienced personnel, adjusting the work schedule and resting the staff, providing training tailored to the needs of the staff, and improving the supervisory and management systems are the most important ways to improve existing conditions and reduce human errors.