The Role of Human Resources Management in Risk and Safety Management of Patient (Case study: Dr. Mojibiyan Hospital, Yazd)

1. Chief of doctor Mojibian hospital, Yazd, Iran
2. Department of Occupational Health, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3. Department of Management, Payam Noor University, Tehran, Iran
4. Occupational health of doctor Mojibian hospital, Yazd, Iran

ARTICLE INFO		ABSTRACT
Original Received: 15 July 2017 Accepted: 3 Dec 2017		Introduction: Reduction in risk possibility in hospitals is an important and vital issue for improving the quality of health care. This research was conducted with the aim of identifying, analyzing and prioritizing risks, providing solutions for reducing or controlling identified risks and examining the effective basics of risk management. Methods: Hospital risk management team consists of 10 experts along with participation of experienced medical staff, tried to identify existing risks in the various hospital departments by FMEA method through inspection, observation and review of processes, within a year. These risks were identified in different classes and finally, the risk priority number (RPN) was calculated using the Excel software and the corresponding formula. Results: Errors in nursing care were identified as the most important nursing work processes in the hospital. Among identified risks, 22 risks were assigned a RPN higher than 150, where corrective proceedings were a priority. The highest RPN (448) was related to lack of implementation for blood injection guidelines and medicate - missed dose process whit PRN (336) got the second place. Conclusion: Major corrective proceedings include the formulation of educational programs, the adoption of policies and procedures, and the establishment of monitoring and evaluating programs to streamline risk management as well as reduction and control the risks in the hospital is considered as main part of the human resource management (HRM).   Keywords: Risk Management, Human Error, Hospital, FMEA, Human Resource
Corresponding Author: Reza Jafari Nodoushan

How to cite this paper:

Health workers are a large part of the workforce (1) and are always prone to many diseases, and their health is seriously endangered from service staff to lab staff (2). Today, all professions and organizations face many risks, which have tended to risk management in order to maintain their own character in the competitive environment of the present day. Reducing the chance of risk in hospitals to improve the quality of health care, effective communication between hospital staff and patients, as well as limiting the proceedings of wrong treatment is very important (3).
According to recent estimates, nearly one out of every 10 people admitted to hospitals, one person experiences an unpleasant event, about half of which can be predicted and about one-third of these events are harmful to the patient, which can be attributed to various forms of elevation residence to death is variable (1). According to the UK Department of Health, medical errors affect over 850,000 people each year in the UK and often have been led to a long time spent by patients in hospital or community care units (4).
Considering that nurses spend more time with patients than other employees, they are more prone to human error than the rest of the staff (5). In any case, the study of the errors of medical care, including nursing, is important in this regard; these errors are on the rise and today are considered as a global problem (6).
In general, there are two attitudes in the analysis of human errors that constitute the major failures of the service system, including the hospital: personal attitude and system attitudes. In personal attitude, center of attention is focused on human errors, and through this attitude, the perpetrators are always blamed for inconvenient acts.
But the centralization of the system's attitude is on the conditions in which permissive humans are working under those conditions and, according to its assumptions; it is inevitable that errors occur even in the best organizations. Thus, according to a systematic attitude, the best way to treat errors is to optimize working systems and processes, and
more importantly, empowering employees through evaluating the performance and training of fallible human rather than retaliate against blaming the wrongdoers (7, 8).
The safety of the hospital environment is very important in terms of economic, human and ethical issues. Risk management in hospitals is a program to reducing the incidence and prevalence of events (9). Risk or danger is a threat from an event or action that unduly affects the ability of an organization to achieve its goals. Risk management is the process of identifying, evaluating and controlling process of potential accidental risks, which specifically, its potential events, damage or lack of change in existing status (10).
Risk management is a set of continuous and developing processes that are used throughout the hospital strategy and must be systematically taken into account all risks associated with the past, present and future (11). the accreditation council of health & therapy institutions in EC 1015 has forced the organization to manage and in accrediting, it will consider its status in reducing accidents (11). One of the most important steps in risk management is the accurate and appropriate risk assessment that should be considered in selecting the method and doing it.
Risk assessment is the basis of any management action in the field of staff safety and health, and in particular patients, which is the key to reducing events and occupational illnesses (1). The assessment should determine the risk of different exposures with error and risk, and then, given the exposure to
the priorities, the management suggestions and solutions are required to provide control over them. Risk assessment techniques may be categorized in a
range and from qualitative approaches to semi-qualitative and quantitative approaches. Limitations such as time, money, manpower, skills, managerial perceptions, community-driven risk communication and political pressures all affect the risk assessment that is to be made (12).
There are several methods for evaluating risk, the most common of which are: FMEA (Analysis of Error Modes and its Effects), FMECA (Analysis of Critical Situations of Errors and Their Effects), HAZOP (Related Hazard Analysis With the process) and FTA (tree error analysis), the most prestigious of which is the FMEA method are used by the US military to manage risks and reduce the effects of natural and abnormal disasters (13).
One of the most common risk assessment methods, especially in hospitals, is the FMEA method that is a structured and group-based approach that in definition is used for identifying, preventing, eliminating or controlling the state of affairs, the causes and effects of potential errors in a service system (14) and can be defined and implemented to reduce or eliminate potentially identified risks, and eventually analysis and proceedings are documented to using them in future if necessary (12). In this study, the FMEA method as one of the risk assessment and risk management tools that has systemic attitude in error (2) has been used to identify and prevent errors, which doing this method requires a series of steps and observing a set of rules that have been used in this study (15, 16).
Human resources management includes appropriate selection of people, training, performance assessment, compensation of the services, etc (17). In spite of the great attention to human resources as a vital source of the success of organizations, there is a significant gap in the
field of human resources risk, and organizations
have little preparation to deal with the risks associated with human capital (18) the three categories mentioned are closely related to the performance assessment, rewards and discipline. In general, performance assessment gains important information about the status of organization's safety performance. They are the proper tools for identifying, managing and improving the system and provide the necessary information for conscious decision making about the proceedings (19).
In management science, we cannot control it until we cannot identify and measure the system's problems and gaps in order to progress the organization and the organization will decline subsequently. Therefore, it is necessary for the organization and staff to perform performance assessment which this identification, evaluation and measurement of the performance lead to system intelligence and stimulate individuals to develop the desired behavior and this is the main part of the formulation and implementation of organizational policies. All organizations, especially those responsible for providing immediate services to the community, are required to provide the environment and conditions in which there is no harm to customers and employees of the organization (20). One of the important factors in reducing or increasing the risks of an organization is human resources and its effective management to growth and development of countries and organizations is not covered on any of the managers, specialists and experts in this area (21). Efficient human resources are considered as valuable finance and assets of each organization. Many organizations are unable to use these resources due to the lack of a competent and capable human resource despite having rich natural resources.Hospitals and medical institutions are not exempted of this issue, and their human resources are formed the basis of the health system. Hence, human resource management in hospitals is seeking to find scientific and applied methods which aimed at increasing the efficiency of therapy staff to take steps order to organization' goals and patient health (22). Given the damages and risks caused by that in the hospital, the purpose of this study is identifying, analyzing and prioritizing the risks by using the FMEA method as an appropriate tool, as well as providing solutions for reducing or controlling identified damages and more importantly determining the role of HRM in controlling and reducing the risks and available errors in various ways.
Methods
This was a descriptive-analytic study. The research population included the medical staff of Dr. Mojibayan Hospital in Yazd. The hospital's risk management team consists of 10 expert individuals along with participation of experienced medical staff, tried to identify existing risks in the various hospital departments by FMEA method through inspection, observation and review of processes, within a year. They identified risks in the categories of medical orders, drug orders, nursing care, file registration, and so on.
After assessing the risks by the FMEA method, the risks were prioritized in collaboration with the team. Byusing tables 1 to 3 (Normal standardized tables for pointing error), and finally, byapplying the points given by the team, Excel software and formula 1 the risk priority score, RPN (Risk Priority Number) was calculated.
Formula 1:

S: Deterioration
O: Probability of occurrence
 D: Probability of discovery

Characteristic	Effect intensity	Rank
It is regrettable deterioration such as risk of death	Dangerous - No warning	10
The deterioration is regrettable, but with warning	Hazardous - with a warning	9
The deterioration is irreparable - the loss of a body member	Very much	8
The deterioration is high, like burning equipment and burning the body	Much	7
The deterioration is high but compensatory. Like Local burn-Sectional injuries	Average	6
The deterioration is low. Such as beat-mild food and drug poisoning	Low	5
The deterioration is very low. But most people feel it - a partial leak of gas in the operating room leaves little effect. Like a scratch	Very low	4
It has a very small effect	Partial effects	3
No effect	Very Partial	2
Characteristic	Nothing	1

Probability of risk	Possible rate of risk	Ranking
Very high: the risk is almost unavoidable	1 in 2 or more	10
	1 in 3	9
High: repeated risks	1 in 8	8
	1 in 20	7
Average: Case risks	1 in 80	6
	1 in 400	5
Low: relatively rare risks	1 in 2000	4
	1 in 15,000	3
Unlikely: improbable risks Probability of risk	1 in 15,000	2
	Less than 1 in 15,000,000	1

Criterion: The probability of detecting a risk	Discoverable capability	Rank
There is no control or if there is, cannot detect potential danger.	Absolutely no	10
There is a very low probability of detecting existing by existing controls.	So insignificant	9
There is little probability of detecting and detecting risk by existing controls.	Insignificant	8
There is a very low probability of detecting risk by existing controls.	very low	7
There is low probability of detecting risk by existing controls.	low	6
In half of the cases it is possible to detect the potential risk by existing controls.	Average	5
There is a fairly large probability to detect the potential risk by existing controls.	Fairly high	4
There is a high probability to detect the potential risk by existing controls.	high	3
There is a lot of probability to detect the potential risk by existing controls.	A lot	2
Potential risk is almost certainly detected and exposed by existing controls.	Certainly	1

Identifying and prioritizing important errors was carried out based on the priority points of the risk assessment obtained, and among them, proposed and corrective proceedings were provided to prevent and control the important and key errors. And finally proportional executive solutions were proposed for each error mode. The RPN score of each error was calculated from 1000, with accepts an error with the rate of
10%, errors with a RPN score of less than 150 were discarded from the review cycle, and for other errors that had scores above 150, were proposed a prioritization and appropriate strategy. Proposed proceedings and suggested solutions were developed by the opinions of relevant experts in the form of an action plan. Action Plan was developed for doing corrective action, and approved by the head of the hospital, and followed by the necessary corrective actions. Subsequently, risk reduction methods and proposed corrective proceedings were examined to determine the role of HRM in risk improvement strategies.
Results
Errors related to nursing cares were identified as one of the most important work processes of nurses in the hospital by using the FMEA technique in hospital risk assessment. Among identified risks, 22 risks were assigned a RPN higher than 150, where corrective proceedings were a priority. As shown in Table 4, the highest RPN was related to lack of implementation of blood injection guidelines.

Row	Risk / Identified risks	Severity	Occurrence	Detection	RPN	Department under evaluated	Predicted Control measures
	Lack of implementation of guidelines for blood injection	8	8	7	448	Therapy departments	-                      Compilation and review of blood transfusion instructions -                      Face-to-face training by the relevant expert in relation to blood transfusion
	The process of medicate - missed dose	6	8	7	336	Therapy departments	-                      Compilation of the medical booklet -                      Teaching how to calculate the dose and use the formula for calculating the dose
	Lack of adequate training for the patient	6	9	6	324	Therapy departments	-                      Development of educational pamphlets for patients at the time of admission and discharge -                      Monitor the training given to patients
	Lack of segregation of infectious waste and non-infectious	5	8	7	280	Therapy departments	-                      training the segregation of waste to employees -                      coloring waste bins and labels for all waste bins
	Failure to determine the blood group of patients who need surgery	10	7	4	280	Therapy departments	-                      Strict supervision of the head nurse and emphasis on supervision by two nurses
	The process of medicate - missed dose	7	7	5	245	Therapy departments	-                      Establishing guidelines for implementing the risk management process by 2 nurses -                      Monitoring the patient's identification process by supervisor
	Lack of sufficient awareness of employees at work	6	8	5	240	Therapy departments	-                      The use of new forces after training courses -                      Applying new forces as auxiliary forces in shift for one month
	The risk of transmission of infection	7	6	5	210	Therapy departments	-                      Emphasis on keeping hands clean -                      Continuous training of therapy staff -                      providing equipment and washing personal protective equipment -                      Standardization in connection with the isolated room
	Being Low the head of the bed at the time of gavage	7	6	5	210	Therapy departments	-                      Continuous training of gavage in patients -                      Empowering personnel through control and supervision of supervisors -                      Applying experienced, enthusiastic and experienced forces
	Creation of Bedsore	8	6	4	192	Therapy departments	-                      Continuing staff training and improving nursing care -                      Continuous monitoring of nursing care delivery
	The process of medicate - giving medicine to the wrong person	8	4	6	192	Therapy departments	-                      Implementing patient identification protocol
	falling patient from the bed	9	7	3	189	Therapy departments	-                      Teaching the importance of patient's initial assessment and checklist of falling from the bed and ensure that the beds are high
	The process of medicate - giving medicine to the wrong person	7	5	5	175	Therapy departments	-                      Implementing the risk management process by 2 nurses -                      Monitoring the patient's identification process by supervisor
	The process of medicate - prescribing the wrong drug (for any reason)	7	5	5	175	Therapy departments	-                      providing the process of medicate -                      Monitoring the process of medicate -                      therapy errors training
	Patient care, injections, blood sampling, suturing and dressing	8	7	3	168	Therapy departments	-                      Vaccination of new employees, use of personal protective equipment, observance of safety points during work
	The risk of contact with sharp objects and infectious materials due to the incorrect separation of department' waste	7	6	4	168	Therapy departments	-                      Continuous training of employees and reminders of the importance of the issue of needle sticks -                      Constant and ongoing monitoring of the correct separation of hospital wastes -                      Laminate preparation for familiarization with waste separation and exposure of employees
	Failure to proper perform the hand washing process	7	8	3	168	Therapy departments	-                      Continuous monitoring of the process of hand washing -                      Continuous Hand washing Training
	Lack of knowledge about high-risk drugs and antideteates	8	7	3	168	Therapy departments	-                      Preparation of a list of high-risk and anti-duoden drugs as same for departments
	Falling from the bed, especially the children	9	6	3	162	Therapy departments	-                      -Install a bad side for all beds -                      - Teaching mothers in the pediatric department -                      - Installation of laminate and warning boards for special attention to the mothers of the pediatric department
	CPR process - nurse unfamiliar with how to work with the Ect device	8	5	5	160	Therapy departments	-                      Nurses' Empowerment in Relation to the Use of Defibrillator and Nursing Continuing Education in Special Sectors -                      Selection of qualified staff for CPR
	Transmission of patient in getting blood for sonography	10	5	3	150	Therapy departments	-                      Teaching the staff about not passing the patient at blood donation with the order of the doctor and in the nursing profession
	Sending wrong laboratory sample due to inaccurate identification of the patient	7	5	4	140	Therapy departments	-                      Providing profile bracelets for all hospitalized patients -                      Correct implementation of the instructions of identifying the patient (correct patient, correct diagnostic, correct therapy) -                      Staff training related to the importance of the subject -                      Formulation of nominal similarity policy

1. Training and empowering nurses to improve nursing cares in the main processes
2. -Assessment of performance and continuous monitoring of nurses' performance, employee assessment and training of staff subsequently.
3. Applying skilled and experienced personnel with scientific interviews and non-accepting staff without early entrance justification training.
4. Sorting forces based on workload.

 
 
 
 
References
1. Yarahmadi R, Aligol M, Eyvazlou M, et al. Risk assessment of exposure to needlestick injuries by healthcare failure mode and effect analysis method in a large hospital, Tehran, Iran, 2011. Qom University of Medical Sciences Journal. 2015; 8(6): 72-80.
2. Rabieyan M, Safdari R, Rahimkhani M, et al. Evaluation of accidental exposures in laboratories' personnel in teaching hospitals of Tehran university of medical sciences (TUMS) during 2004 to 2005. Journal of Payavard Salamat. 2008; 2(3): 33-41.
3. Yarmohammadian M, Tofighi S, Esfahani SS, et al. Risks involved in medical records processes of Al-Zahra hospital. Health Information Management. 2007; 4(1): 51-59.
4. Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Applied Ergonomics. 2006; 37(5): 669-679.
5. Tanha F, Mazloumi A, Faraji V, et al. Evaluation of human errors using standardized plant analysis risk human reliability analysis technique among delivery emergency nurses in a hospital affiliated to Tehran university of medical sciences. Journal of Hospital. 2015; 14(3): 57-66.
6. Dhingra KR, Elms A, Hobgood C. Reducing error in the emergency department: a call for standardization of the sign-out process. Annals of Emergency Medicine. 2010; 56(6): 637-642.
7. Jensen RC. Risk reduction methods for occupational safety and health. Canada: John Wiley & Sons; 2012.
8. Nezamodini ZA, Orosi M, Mombeni B. Assessment of human errors in paper machines of pars paper industrial group by Predictive Human Error Analysis (PHEA). Jundishapur Journal of Health Sciences. 2013; 4(4): 17-24.
9. Purreza A, Akbari F, Khodabakhshnejad V. Maintenance and safety management on diagnostic departments on hospitals affiliated in Gilan. Health Information Management Journal. 2006; 5(8): 5-6.
10. Babaie M, Zanjani M. New approach on organizational effectiveness: risk management. Tadbir Journal. 2005; 6(170): 3-6.
11. Zaboli R, Karamali M, Salem M, et al. Risk management assessment on selected wards of a Military hospital. Journal of Military Medicine. 2011; 12(4): 197-202.
12. Brito AJ, de Almeida AT. Multi-attribute risk assessment for risk ranking of natural gas pipelines. Reliability Engineering & System Safety. 2009; 94(2): 187-198.
13. Reason J. Human error: models and management. Western Journal of Medicine. 2000; 320(7237): 768-770.
14. Maleki A, Zohour A, Ebadifard A, et al. An integrated approach in healthcare system in accordance with QFD/FMEA. Payesh. 2010; 9(2): 117-130.
15. mohammadfam i. Safety engineering. Tehran: Fanavaran publication; 2013.
16. Mosadeghrad AM. Handbook of hospital professional organisation and management (2). Dibagran Tehran,
Iran; 2004.
17. Fheili MI. Developing human resources key risk indicators—Know Your Staff (KYS) practices. Journal of Operational Risk. 2006; 1: 71-85.
18. Meyer M, Roodt G, Robbins M. Human resources risk management: governing people risks for improved performance: opinion paper. SA Journal of Human Resource Management. 2011; 9(1): 1-12.
19. Barkhordari A, Dehghani A, Kianfar A, et al. Safety performance evaluation using proactive indicators in a selected industry. Journal of Occupational Hygiene Engineering. 2015; 1(4): 49-59.
20. Wachter R. Understanding patient safety: McGraw Hill Professional; 2012.
21. Abbaszade HA, Mahmoodi A, Noori A. Positive behavior and its effect on organizational behavior and quality of work life. Management Studies in Development and Evolution. 2014; 23(74): 137-159.[Persian].
22. Rezaei Rad MM, Doaei H. Relationship between human resource strategies, perceived organizational support and organizational commitment of nurses: Developing the pattern. Journal of Health Promotion Management. 2012; 1(2): 35-43.
23. Attar Jannesar Nobari F, Yousefinezhadi T, Behzadi Goodari F, et al. Clinical risk assessment of intensive care unit using failure mode and effects analysis. Journal of Hospital. 2015; 14(2): 49-59.
24. Robinson DL, Heigham M, Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer. The Joint Commission Journal on Quality and Patient Safety. 2006; 32(3): 161-166.
25. Ghanjal A, Sedaghat A, Motaqhey M, et al. Risk management and assessment of field emergency center using FMEA method. Journal of Military Medicine. 2008; 10(3): 167-174.
26.Nembhard IM, Edmondson AC. Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior. 2006;
27(7): 941-966.
27. Bordbar G, Mosavi S, Moradi K. An analysis of employee training needs using fuzzy topsis and dematal techniques: a case study in southern Khorasan governer-general office. Journal of Educational Planning Studies. 2012; 1(1):
105-129.
28. Subramaniam C, Mohd. Shamsudin F, Mohd Zin ML, et al. Safety management practices and safety compliance in small medium enterprises: Mediating role of safety participation. Asia-Pacific Journal of Business Administration. 2016; 8(3): 226-244.
29. Čech M, Samolejová A, Li J, et al. Comparison of human resource management practices in czech and chinese metallurgical companies. Proceedings of the 2nd Czech-China Scientific Conference 2016; 2017: InTech.
30. Lahiani N, El Mhamedi A, Hani Y, et al. A novel improving method of industrial performance based on human resources management. IFAC-PapersOnLine. 2016; 49(28): 262-267.
31. KoC M, Cavus MF, Saraçoglu T. Human resource management practices, job satisfaction and organizational commitment. International Journal of Academic Research in Business and Social Sciences. 2014; 4(9): 178.
32. Hong ENC, Hao LZ, Kumar R, et al. An effectiveness of human resource management practices on employee retention in institute of higher learning: A regression analysis. International Journal of Business Research and Management. 2012; 3(2): 60-79.