Evaluation and analysis of human error in the use of equipment using PUEA technique and fuzzy logic

Abstract

Background and Objectives:The main cause of incidents is human error. The occurrence of these errors in the use of medical equipment can result in harm to the patient, the destruction of equipment, the imposition of economic damages, and the deterioration of the credentials of the health sectors. Hence, the identification, evaluation and management of errors in the use of these equipment is very critical. The present study was conducted to reduce the risk of human errors in using a medical device in one of the hospitals in Iran. Methods:The study subject was a ventilator device, which was selected considering the high usage and the criticality of its use in hospitals. Identification and evaluation of human error were performed using the PUEA technique, as well as quantification of errors, and reduction of uncertainty in estimating the significance of detected human errors using fuzzy logic.Results: Based on the findings, 33 errors were detected in the use of the ventilator device. The most common types of errors were the type of error in operation. (72.72%). The most important causes of errors were slips and lapses (42.42%). The main primary consequences for the predicted errors were the device not being sterilized and the possibility of transmission of microbes to patients. In 42.42% of the cases, errors were not recoverable. The results of the PUEA technique and fuzzy logic showed that there is no relationship between the type of error, frequency of its occurrence, and the probability of error occurrence. Conclusion:In human error studies, the combined use of risk identification techniques and a quantitative approach that determines the probability of identified errors can reduce uncertainty in the final results.

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