Procedimiento para el analisis y la prevención de errores de medicación usando el enfoque de la ergonomia

Medication errors represent a public health problem that affects patient's safety and the quality of health services on a global scale. This article presents a procedure for the analysis and prevention of medication errors from an ergonomics perspective, exemplifying its application through an illustrative case study of the administration of an injectable medication. As part of this procedure, hierarchical task analysis (HTA) methods for analyzing the task and, systematic human error reduction, and the prediction approach (SHERPA) for identifying error modes were included. A qualitative risk matrix is proposed. The proposed procedure consisted of four stages: 1) selection of the task under study, 2) detailed analysis of the task, 3) prediction of the possibility of error, and 4) development of strategies for error reduction.