Iranian Red Crescent Medical Journal (IRCMJ)

Current Issue

By Issue

By Author

By Subject

Author Index

Keyword Index

About Journal

Aims and Scope

Editorial Board

Publication Ethics

Indexing and Abstracting

Related Links

FAQ

Peer Review Process

Journal Metrics

News

Author Guidelines

Article Processing Charge

A Causal Model to Design more Effective Policies and Practices in Error Management in the Healthcare Industry

Document Type : Research articles

Authors

1 School of Environment, College of Engineering, University of Tehran, Tehran, Iran.

2 1. Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 2. Faculty of Environment, University of Tehran, Tehran, Iran 2Department of Occupational Health Engineering, Faculty of Health, Iran University of Medical Sciences, Tehran, Iran.

3 MSc of Health, Safety and Environment Engineering, Department of Health, Safety and Environment Engineering, School of Health, Islamic Azad University, Najafabad Branch, Isfahan, Iran.

4 MSc Student of Occupational Health Engineering, Department of Occupational Health Engineering, School of Health, Tehran University of Medical Sciences, Tehran, Iran.

5 MSc of Toxicology, Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

6 BSc of Occupational Health Engineering, Department of Occupational Health Engineering, School of Health, Zahedan University of Medical Sciences, Zahedan, Iran.

7 1. Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran 2. Department of Occupational Health Engineering, Faculty of Health, Iran University of Medical Sciences, Tehran, Iran.

Abstract

Background: Identification of the factors contributing to the errors of medical staff and examining the causal relationships among those factors can help better manage and design more effective policies and practices.
Objectives: This study aimed to identify the causes and factors affecting medical error management and determine a model for better management of such errors.
Methods: This descriptive-analytical study was conducted in two qualitative and quantitative phases. In the quantitative part of the study, the factors related to medical error management were identified and validated through reviewing previous studies and interviewing some specialists. Following that, the fuzzy decision-making trial and evaluation method was used for structural modeling of the factors and investigating the causal relationships among them in the quantitative part.
Results: In this study, the results showed that the "education and learning from error" subfactor had the most significant impact on the system. The second highly effective subfactors in the management of medical errors were "organizational communication and improved information access", "safety culture and climate", and "policies, procedures, and guidelines". In addition, the "safety culture and climate" was the most important factor that had the most critical impact on the system. Moreover, the "handoff conversations and communication" subfactor was mostly influenced by the other factors, followed by the "incident reporting system", "error prevention and corrective measures", "safety culture and climate", and "individuals' participation".  
Conclusion: According to the results of this study, the health care industry should take into consideration both organizational and individual factors in error management. In order to achieve better planning and higher performance in error management, increase patient safety, and ultimately improve the quality of hospital services, it is suggested to consider the causes and factors affecting the system.

Keywords

References
  1. Khan A, Spector ND, Baird JD, Ashland M, Starmer AJ, Rosenbluth G, et al. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018;363:k4764. doi: 10.1136/bmj.k4764. [PubMed: 30518517].
  2. Welsh D, Zephyr D, Pfeifle AL, Carr DE, Fink JL 3rd, Jones M. Development of the barriers to error disclosure assessment tool. J Patient Saf. 2017;30:1-22. doi: 10.1097/PTS.0000000000000331. [PubMed: 28671908].
  3. Valley M, Stallones L. A thematic analysis of health care workers’ adoption of mindfulness practices. Workplace Health Saf. 2018;66(11):538-44. doi: 10.1177/2165079918771991. [PubMed: 29806801].
  4. Ravindran S, Thomas-Gibson S, Murray S, Wood E. Improving safety and reducing error in endoscopy: simulation training in human factors. Frontline Gastroenterol. 2019;10(2):160-6. doi: 10.1136/flgastro-2018-101078. [PubMed: 31205657].
  5. Saravi BM, Mardanshahi A, Ranjbar M, Siamian H, Azar MS, Asghari Z, et al. Rate of medical errors in affiliated hospitals of Mazandaran university of medical sciences. Mater Sociomed. 2015;27(1):31-4. doi: 10.5455/msm.2014.27.31-34. [PubMed: 25870528].
  6. Sarfati L, Ranchon F, Vantard N, Schwiertz V, Larbre V, Parat S, et al. Human‐simulation‐based learning to prevent medication error: a systematic review. J Eval Clin Pract. 2019;25(1):11-20. doi: 10.1111/jep.12883. [PubMed: 29383867].
  7. Lisby M, Nielsen LP, Brock B, Mainz J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care. 2010;22(6):507-18. doi: 10.1093/intqhc/mzq059. [PubMed: 20956285].
  8. Cousins DD, Heath WM. The national coordinating council for medication error reporting and prevention: promoting patient safety and quality through innovation and leadership. Joint Commission J Qual Patient Saf. 2008;34(12):700-2. doi: 10.1016/S1553-7250(08)34091-4.
  9. Spath[S1]  PL. Error reduction in health care: a systems approach to improving patient safety. J Nurs Regulat. 2012;2(4):60. doi: 10.1016/S2155-8256(15)30255-6.
  10. Fontela E, Gabus A. The dematel observer, battelle geneva research center, geneva, switzerland. Modern Econ. 1976;7(9):16-3287.
  11. Lin CJ, Wu WW. A causal analytical method for group decision-making under fuzzy environment. Exp Syst Appl. 2008;34(1):205-13. doi: 10.1016/j.eswa.2006.08.012.
  12. Vosoughi S, Chalak MH, Rostamzadeh S, Taheri F, Farshad AA, Motallebi Ghayen M. A cause and effect decision making model of factors influencing falling from height accidents in construction projects using Fuzzy-DEMATEL technique. Iran Occup Health J. 2019;16(2):79-93.
  13. Bavafaa A, Mahdiyarb A, Marsonoa AK. Identifying and assessing the critical factors for effective implementation of safety programs in construction projects. Saf Sci. 2018;106:47-56. doi: 10.1016/j.ssci.2018.02.025.
  14. Wang L, Cao Q, Zhou L. Research on the influencing factors in coal mine production safety based on the combination of DEMATEL and ISM. Saf Sci. 2018;103:51-61. doi: 10.1016/j.ssci.2017.11.007.
  15. Meng X, Chen G, Zhu G, Zhu Y. Dynamic quantitative risk assessment of accidents induced by leakage on offshore platforms using DEMATEL-BN. Int J Naval Arch Ocean Eng. 2019;11(1):22-32. doi: 10.1016/j.ijnaoe.2017.12.001.
  16. Wu WW, Lee YT. Developing global managers’ competencies using the fuzzy DEMATEL method. Exp Syst Appl. 2007;32(2):499-507. doi: 10.1016/j.eswa.2005.12.005.
  17. Afsharkazemi MA, Manouchehri J, Salarifar M, Nasiripour AA. Key factors affecting the hospital performance: a qualitative study using fuzzy logic. Qual Quant. 2013;47(6):3559-73. doi: 10.1007/s11135-012-9739-7.
  18. Hudson M, Smart A, Bourne M. Theory and practice in SME performance measurement systems. Int J Operat Prod Manag. 2001;21(8):1096-115. doi: 10.1108/EUM0000000005587.
  19. Waltz CF, Bausell BR. Nursing research: design statistics and computer analysis. Philadelphia: Davis FA; 1981.
  20. Bacudio LR, Benjamin MF, Eusebio RC, Holaysan SA, Promentilla MA, Yu KD, et al. Analyzing barriers to implementing industrial symbiosis networks using DEMATEL. Sustainable Prod Consumpt. 2016;7:57-65. doi: 10.1016/j.spc.2016.03.001.
  21. Gandhi S, Mangla SK, Kumar P, Kumar D. A combined approach using AHP and DEMATEL for evaluating success factors in implementation of green supply chain management in Indian manufacturing industries. Int J Logist Res Appl. 2016;19(6):537-61. doi: 10.1080/13675567.2016.1164126.
  22. Patil SK, Kant R. A fuzzy AHP-TOPSIS framework for ranking the solutions of knowledge management adoption in supply chain to overcome its barriers. Exp Syst Appl. 2014;41(2):679-93. doi: 10.1016/j.eswa.2013.07.093.
  23. Li R-J. Fuzzy method in group decision making. Comput Mathem Appl. 1999;38(1):91-101. doi: 10.1016/S0898-1221(99)00172-8.
  24. Beckett CD, Kipnis G. Collaborative communication: integrating SBAR to improve quality/patient safety outcomes. J Healthc Qual. 2009;31(5):19-28. doi: 10.1111/j.1945-1474.2009.00043.x. [PubMed: 19813557].
  25. Doshmangir L, Ravaghi H, Akbari Sari A, Mostafavi H. Challenges and solutions facing medical errors and adverse events in Iran: a qualitative study. J Hosp. 2016;15(1):31-40.
  26. Pazokian M, Zagheri Tafreshi M, Rassouli M. Factors affecting medication errors from nurses' perspective: lessons learned. Iran J Med Educ. 2013;13(2):98-113.
  27. Chiu CH, Pan WH, Wei CJ. Does organizational culture impact patient safety management? Asian J Health Informat Sci. 2008;3(1-4):88-100. doi: 10.6412/AJHIS.200812.0088.
  28. Nieva V, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care. 2003;12(Suppl 2):ii17-23. doi: 10.1136/qhc.12.suppl_2.ii17. [PubMed: 14645891].
  29. Nabilah H, Idris O, Eliana M, Roslinah A, Aishah A, Noriah B. Do we communicate openly in healthcare delivery. Int J Curr Res Acad Rev. 2014;1:30-7.
  30. La Pietra L, Calligaris L, Molendini L, Quattrin R, Brusaferro S. Medical errors and clinical risk management: state of the art. Acta Otorhinolaryngol Ital. 2005;25(6):339-46. [PubMed: 16749601].
  31. Salas E, King HB, Rosen M. Improving teamwork and safety: toward a practical systems approach, a commentary on Deneckere et al. Soc Sci Med. 2012;75(6):986-9. doi: 10.1016/j.socscimed.2012.02.055. [PubMed: 22627017].
  32. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-90. doi: 10.1136/qhc.13.suppl_1.i85. [PubMed: 15465961].
  33. Walston SL, Al-Omar BA, Al-Mutari FA. Factors affecting the climate of hospital patient safety: a study of hospitals in Saudi Arabia. Int J Health Care Qual Assur. 2010;23(1):35-50. doi: 10.1108/09526861011010668. [PubMed: 21387862].
  34. Bell SK, Delbanco T, Anderson-Shaw L, McDonald TB, Gallagher TH. Accountability for medical error: moving beyond blame to advocacy. Chest. 2011;140(2):519-26. doi: 10.1378/chest.10-2533. [PubMed: 21813531].
  35. Vozikis A. Information management of medical errors in Greece: The MERIS proposal. Int J Informat Manag. 2009;29(1):15-26. doi: 10.1016/j.ijinfomgt.2008.04.012.
  36. Pukk Härenstam K, Elg M, Svensson C, Brommels M, Øvretveit J. Patient safety as perceived by Swedish leaders. Int J Health Care Qual Assur. 2009;22(2):168-82. doi: 10.1108/09526860910944656. [PubMed: 19536967].
  37. Marcatto F, Colautti L, Filon FL, Luis O, Di Blas L, Cavallero C, et al. Work-related stress risk factors and health outcomes in public sector employees. Saf Sci. 2016;89:274-8. doi: 10.1016/j.ssci.2016.07.003.
  38. Moumtzoglou A. Reporting adverse events: Greek doctor and nurse attitudes. Int J Health Care Qual Assur. 2010;23(7):680-7. doi: 10.1108/09526861011071607. [PubMed: 21125963].
  39. Fein S, Hilborne L, Kagawa-Singer M, Spiritus E, Keenan C, Seymann G, et al. A conceptual model for disclosure of medical errors. Rockville (MD): Agency for Healthcare Research and Quality; 2005. [PubMed: 21249826].
  40. Kline TJ, Willness C, Ghali WA. Determinants of adverse events in hospitals--the potential role of patient safety culture. J Healthc Qual. 2008;30(1):11-7. doi: 10.1111/j.1945-1474.2008.tb01122.x. [PubMed: 18257452].
  41. Pizzi L, Goldfarb NI, Nash DB. Crew resource management and its applications in medicine. Making Health Care Safer. 2001;44:511-9.
  42. Kalra J. Medical errors: overcoming the challenges. Clin Biochem. 2004;37(12):1063-71. doi: 10.1016/j.clinbiochem.2004.08.008. [PubMed: 15589811].
  43. Caty MG. Complications in pediatric surgery. Florida: CRC Press; 2008. P. 19-27.
  44. Kim J, An K, Kim MK, Yoon SH. Nurses' perception of error reporting and patient safety culture in Korea. West J Nurs Res. 2007;29(7):827-44. doi: 10.1177/0193945906297370. [PubMed: 17636243].
  45. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320(7237):781-5. doi: 10.1136/bmj.320.7237.781. [PubMed: 10720367].
  46. Haghighi MH, Dehghani M, Teshnizi SH, Mahmoodi H. Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran. Health Inf Manag. 2014;43(2):35-42. [PubMed: 24948664].
  47. Tran DT, Johnson M. Classifying nursing errors in clinical management within an Australian hospital. Int Nurs Rev. 2010;57(4):454-62. doi: 10.1111/j.1466-7657.2010.00846.x. [PubMed: 21050197].
  48. Keselman A, Smith CA. A classification of errors in lay comprehension of medical documents. J Biomed Inform. 2012;45(6):1151-63. doi: 10.1016/j.jbi.2012.07.012. [PubMed: 22925723].
  49. Farhan J, Al-Jummaa S, Alrajhi AA, Al-Rayes H, Al-Nasser A. Documentation and coding of medical records in a tertiary care center: a pilot study. Ann Saudi Med. 2005;25(1):46-9. doi: 10.5144/0256-4947.2005.46. [PubMed: 15822494].
  50. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-94. doi: 10.1097/00001888-200402000-00019. [PubMed: 14744724].
  51. Pirnejad H, Niazkhani Z, Berg M, Bal R. Intra-organizational communication in healthcare--considerations for standardization and ICT application. Methods Inf Med. 2008;47(4):336-45. [PubMed: 18690367].
  52. Choo J, Hutchinson A, Bucknall T. Nurses' role in medication safety. J Nurs Manag. 2010;18(7):853-61. doi: 10.1111/j.1365-2834.2010.01164.x. [PubMed: 20946221].
  53. Fennigkoh L, Haro D. Human factors and the control of medical device-related error. It’s making the world a smarter place. New Jersey: Lawrence Erlbaum Associates; 2010. P. 39.
  54. Carroll JS, Williams M, Gallivan TM. The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Qual Saf. 2012;21(7):586-93. doi: 10.1136/bmjqs-2011-000614. [PubMed: 22328456].
  55. Abraham J, Kannampallil T, Brenner C, Lopez KD, Almoosa KF, Patel B, et al. Characterizing the structure and content of nurse handoffs: a sequential conversational analysis approach. J Biomed Inform. 2016;59:76-88. doi: 10.1016/j.jbi.2015.11.009. [PubMed: 26625846].
  56. Amato‐Vealey EJ, Barba MP, Vealey RJ. Hand‐off communication: a requisite for perioperative patient safety. AORN J. 2008;88(5):763-74. doi: 10.1016/j.aorn.2008.07.022. [PubMed: 19024783].
  57. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm. 2002;59(21):2089-92. doi: 10.1093/ajhp/59.21.2089. [PubMed: 12434722].
  58. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc; 2010;85(1):53-62. doi: 10.4065/mcp.2009.0248. [PubMed: 20042562].
  59. Zabari ML, Southern NL. Effects of shame and guilt on error reporting among obstetric clinicians. J Obstet Gynecol Neonatal Nurs. 2018;47(4):468-78. doi: 10.1016/j.jogn.2018.03.002. [PubMed: 29678432].
  60. Wilson KA, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005;14(4):303-9. doi: 10.1136/qshc.2004.010090. [PubMed: 16076797].
  61. Bleetman A, Sanusi S, Dale T, Brace S. Human factors and error prevention in emergency medicine. Emerg Med J. 2012;29(5):389-93. doi: 10.1136/emj.2010.107698. [PubMed: 21565880].
  62. McIlvaine WB. Situational awareness in the operating room: a primer for the anesthesiologist. Semin Anesth Perioperat Med Pain. 2007;26(3):167-72. doi: 10.1053/j.sane.2007.06.001.
  63. Singh H, Giardina TD, Petersen LA, Smith MW, Paul LW, Dismukes K, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf. 2012;21(1):30-8. doi: 10.1136/bmjqs-2011-000310. [PubMed: 21890757].
  64. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999;34(3):373-83. doi: 10.1016/s0196-0644(99)70134-4. [PubMed: 10459096].
  65. Sun R, Marshall DC, Sykes MC, Maruthappu M, Shalhoub J. The impact of improving teamwork on patient outcomes in surgery: a systematic review. Int J Surg. 2018;53:171-7. doi: 10.1016/j.ijsu.2018.03.044. [PubMed: 29578095].
  66. Ramaswamy RS, Tiwari T, Ramaswamy HF, Akinwande O. Teamwork and communication in interventional radiology. J Radiol Nurs. 2017;36(4):261-4. doi: 10.1016/j.jradnu.2017.10.003.
  67. Hwang JI, Ahn J. Teamwork and clinical error reporting among nurses in Korean hospitals. Asian Nurs Res (Korean Soc Nurs Sci). 2015;9(1):14-20. doi: 10.1016/j.anr.2014.09.002. [PubMed: 25829205].
  68. Motycka C, Egelund EF, Gannon J, Genuardi F, Gautam S, Stittsworth S, et al. Using interprofessional medication management simulations to impact student attitudes toward teamwork to prevent medication errors. Curr Pharm Teach Learn. 2018;10(7):982-9. doi: 10.1016/j.cptl.2018.04.010. [PubMed: 30236437].
  69. Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, et al. Hospitalized patients’ participation and its impact on quality of care and patient safety. Int J Qual Health Care. 2011;23(3):269-77. doi: 10.1093/intqhc/mzr002. [PubMed: 21307118].
  70. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-48. doi: 10.1177/1077558709342254. [PubMed: 19671916].
  71. Hashemi F, Nasrabadi AN, Asghari F. Factors associated with reporting nursing errors in Iran: a qualitative study. BMC Nurs. 2012;11:20. doi: 10.1186/1472-6955-11-20. [PubMed: 23078517].
  72. Kagan I, Barnoy S. Organizational safety culture and medical error reporting by Israeli nurses. J Nurs Scholarsh. 2013;45(3):273-80. doi: 10.1111/jnu.12026. [PubMed: 23574516].
  73. Spath PL. Error reduction in health care: a systems approach to improving patient safety. J Nurs Regulat. 2012;2(4):60. doi: 10.1016/S2155-8256(15)30255-6.
  74. Safarpour H, Tofighi M, Malekyan L, Bazyar J, Varasteh S, Anvary R. Patient safety attitudes, skills, knowledge and barriers related to reporting medical errors by nursing students. Int J Clin Med. 2017;8(1):11. doi: 10.4236/ijcm.2017.81001.
  75. Bognár A, Barach P, Johnson JK, Duncan RC, Birnbach D, Woods D, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;85(4):1374-81. doi: 10.1016/j.athoracsur.2007.11.024. [PubMed: 18355531].
  76. Landberg HE, Berg P, Andersson L, Bergendorf U, Karlsson JE, Westberg H, et al. Comparison and evaluation of multiple users' usage of the exposure and risk tool: stoffenmanager 5.1. Ann Occup Hyg. 2015;59(7):821-35. doi: 10.1093/annhyg/mev027. [PubMed: 25858432].

Iranian Red Crescent Medical Journal (IRCMJ)
Volume 23, Issue 2 - Serial Number 2
2021
Files
History
  • Receive Date: 30 September 2020
  • Revise Date: 20 May 2024
  • Accept Date: 27 January 2024
  • First Publish Date: 27 January 2024
  • Publish Date: 01 February 2021
Share
How to cite
Statistics