1. Introduction The healthcare delivery quality and patient safety improvement are prominence issues in healthcare systems. Delivery of healthcare depends on implicated procedure and interaction between patient, providers, organization and technology[1] which all of them may be causes of medical error or faults in a system. This condition, most of the time accompanies with uncertainties making the healthcare a high-risk system and it is confirmed by some information such as the annual death from medical error was 48000-98000 in 1999 and medical error is the third most common cause of death in the US in 2013 according to the report of Institute of Medicine(IOM) and statistical report of Central for Disease Control (CDC), respectively [2],[3].
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[6] used fault tree analysis to assess the reliability of the system in preventing wrong site surgery. Fault Tree Analysis was used to model error paths and identify root causes in Postoperative Bloodstream Infection steps by[7] in this study qualitative analysis is not considered. The risk of possible incident scenarios of preparation domain of radiation treatment is analyzed by FTA and used subjective probabilities from experts and compared results with incident report data in [8]. Dynamic FTA with Markov chain was used by [9] to analyze the risk of gastric esophageal surgery considering dependent time variables. Nevertheless, standard FTA has some constraints especially when there are complex and large systems with a high interaction between dependence or independence components, or with multi-state variable, common cause failures and when causal relationships are not followed Boolean logic and uncertain information considered in a model[10, 11]. Therefore, by this limitation, FTA could not be an effective tool for safety and risk studies in complicated healthcare …show more content…
As ACLS quality extremely relies on human performance, the reliability of technology and equipment is not considered. To this end, and due to there has been no conducted research about quantitative analysis of AClS quality based on human performance, tree stages was developed to task analysis. In the first step, human activities and tasks which are more relevant to the improper quality ACLS occurrence were identified based on American Heart Association guidelines [24] and the features to perform these tasks properly were determined. In the second step, task categorized rely on staff action leading to clinical incidents[25] and finally, the probability of improper performance foe each task. After task analysis, by considering two states for each activity and defining the relationships among activities the FTA is built and the probability of improper quality of ACLS team performance is calculated. After that to exploit BBNs advantages, FT converted onto BBNs and Finally different scenarios are defined to demonstrate efficiency and flexibility off BBNs model and to evaluate the probability influences of other factors such as the team leader presence, audiovisual feedback, differential effects of activity, dependency among some task and uncertainty knowledge of experts on the quality of
[6] used fault tree analysis to assess the reliability of the system in preventing wrong site surgery. Fault Tree Analysis was used to model error paths and identify root causes in Postoperative Bloodstream Infection steps by[7] in this study qualitative analysis is not considered. The risk of possible incident scenarios of preparation domain of radiation treatment is analyzed by FTA and used subjective probabilities from experts and compared results with incident report data in [8]. Dynamic FTA with Markov chain was used by [9] to analyze the risk of gastric esophageal surgery considering dependent time variables. Nevertheless, standard FTA has some constraints especially when there are complex and large systems with a high interaction between dependence or independence components, or with multi-state variable, common cause failures and when causal relationships are not followed Boolean logic and uncertain information considered in a model[10, 11]. Therefore, by this limitation, FTA could not be an effective tool for safety and risk studies in complicated healthcare …show more content…
As ACLS quality extremely relies on human performance, the reliability of technology and equipment is not considered. To this end, and due to there has been no conducted research about quantitative analysis of AClS quality based on human performance, tree stages was developed to task analysis. In the first step, human activities and tasks which are more relevant to the improper quality ACLS occurrence were identified based on American Heart Association guidelines [24] and the features to perform these tasks properly were determined. In the second step, task categorized rely on staff action leading to clinical incidents[25] and finally, the probability of improper performance foe each task. After task analysis, by considering two states for each activity and defining the relationships among activities the FTA is built and the probability of improper quality of ACLS team performance is calculated. After that to exploit BBNs advantages, FT converted onto BBNs and Finally different scenarios are defined to demonstrate efficiency and flexibility off BBNs model and to evaluate the probability influences of other factors such as the team leader presence, audiovisual feedback, differential effects of activity, dependency among some task and uncertainty knowledge of experts on the quality of