SHERPA Technique as an Approach to Healthcare Error Management and Patient Safety Improvement: A Case Study among Nurses

Abstract

Background: Overcoming the challenge of human error occurrence in the healthcare section and patient safety improvement is impossible without understanding the nature of human error and without considering the fundamentals of human factors and ergonomics in designing and implementing sociotechnical systems. Therefore, the first step is to identify medical errors and their causes, using standard methods. Objectives: The aim of this study was to identify and evaluate human errors among nurses in the women’s infectious diseases ward in an educational hospital in the city of Qom in 2015. Methods: This cross-sectional study was performed to identify the medical errors among sixteen female nurses working in the women’s infectious diseases ward, using SHERPA. Hierarchical task analysis (HTA) was performed; errors were identified by checklist and risk assessment was then carried out. Results: One hundred fifty-nine errors were identified and evaluated in 89 tasks. Most of the detected errors were of the action type (74.21%) and the least errors were of the selection type (0.63%). The least number of the errors’ risk level was placed in the undesirable, and the highest was in the unacceptable level. Conclusions: Since the majority of the errors were of the action type, proper measures should be taken to prioritize them in disease control. In addition, designing a treatment process based on human factors and ergonomic principles is highly recommended to enhance the quality of services, improve patient safety and reduce errors. With respect to task analysis, the SHERPA is a good technique to evaluate and monitor medical errors.