Identification and Evaluation of Human Errors among the nurses of Coronary Care Unit Using CREAM Techniques

Adverse events are injuries and problems are derived from management than the original condition. In particular, Intensive care units are as a place of significant human errors and preventable adverse events in the health care system. The present study was conducted to identify and evaluate human errors among cardiac intensive care nurses in a teaching hospital in Hamadan city. This qualitative study was conducted using the cream technique. in this study nursing job were analyzed using hierarchical task analysis. Then the work sheet of cream techniques completed through observation and interviews with the nurses. Data analysis was performed using spss-16 software. Findings show that the maximum probability of error are in setting tasks and use DC shock in urgent cases, data recording in the hospital system, said start code resuscitation of heart and lung (CPR) respectively 0.02108, 0.02088 and 0.02086. Minimum probability of error were Determine nutritional needs and diet, gavages and necessary care and giving oral medications respectively 0.01100, 0.01013 and 0.00966. The most important suggestion to improve of working situation and reducing of human error probability are modification of nurses shift work, providing of practical training and decrease of additional duties.