Error Prevention Research Articles

Development of a Traffic Speed Limit Sign Detection System Based on Yolov4 Network

Recent developments in artificial intelligence technologies have accelerated the transition to smart systems in the automotive industry. By anticipating driving conditions, these technologies enable the prevention of driver-related errors and accidents as well as the provision of crucial information to the driver. In this study, an artificial intelligence-based system is designed to provide information to drivers about speed signs on the road in order to support traffic safety. In this system, Yolov4 model is used to achieve high speed and accuracy levels. After the model training, the model was validated and the test results were found to be 98%.

The Cohesion of the Error Management Culture and Risk Management Maturity in Healthcare


 
 
 
 Errors and mistakes are an inevitable part of organisational life and certainly life in general. However, errors result in adverse events. The consequences of them influence the safety of the staff and the health of patients. The focus is on the following fundamental question regarding the scientific problem at the theoretical level: How the error management culture relates to risk management maturity in healthcare? The aim of this study is to theoretically ground the importance of the link between the error management culture and risk management maturity in the field of healthcare. Methods of the research are literature review and the critical analysis of the latest scientific articles on the issue. In conclusion, the error management culture leads to the lowered occurrence of adverse events, improved error reporting, improved prevention of medical errors, improved quality and safety of the clinical services, and proactivity with regard to errors.
 
 
 

Labelling of intravenous drug delivery devices in critically ill patients: A scoping review.

Labelling is a strategy that contributes to the correct and faster identification of drugs, minimizing misidentification. There is a gap in knowledge on optimal labelling standards for intravenous (IV) devices applied to the care of critically ill patients. The goal of this article was to map existing knowledge on the labelling of IV drug delivery devices in critically ill patients for the prevention of medication errors. This was a scoping review conducted according to the JBI methodology in the LILACS, MEDLINE, CINAHL, IBECS, Scopus, Embase and Web of Science databases, and on the websites of specialized institutions. Searches were conducted up to December 2022 for scientific articles and grey literature that addressed the labelling of IV devices in intensive care units, emergency departments, and anaesthesia units. The data were collected using a structured form and were later classified, summarized, and aggregated to map the knowledge related to the review question. Twenty-one documents were included, which demonstrated variability in label use with IV drug delivery devices. The following features of structure and design stood out: printed format, colour coding, letter size differentiation, and the use of sturdy material. In terms of information, the name of the drug, dose, date and time of preparation, identification of the patient, and who prepared it were found. The identified patterns contributed to the reduction of drug misidentification and the development of timelier drug labelling and administration. The evidence supports the development of standardized labels for the prevention of medication errors.

Quality II: A new paradigm for construction

The Quality I paradigm utilizes an error prevention strategy to avert rework in construction. The effectiveness of this paradigm is questionable as rework has become an innate feature of practice. If rework is to be mitigated in construction projects, a new paradigm is needed to challenge conventional thinking and offer a different perspective on managing errors. We introduce a new paradigm, Quality II, by drawing on a narrative review, emerging best practices deployed in construction, and contemporary developments in safety (e.g., Safety II and III). The implications of a Quality II paradigm for theory development and practice are also examined. The contributions of this paper are twofold as we: (1) provide construction organizations with a new approach for managing and learning how to handle (i.e., learning through) errors, and thus provide them with the ability to adapt and respond to varying conditions effectively; and (2) align Quality II with contemporary safety paradigms to offset competing demands enabling construction organizations to maximize the use of their limited resources better. By curbing rework, the performance and productivity of projects and the profitability of construction organizations will improve.

Evaluation of the Relationship between School Age Children's Refractive Errors and Outdoor Activity

Abstract Background Uncorrected refractive errors, one of the most common health problems of the pediatric age group. It is known that outdoor activities are effective in the prevention of refractive errors in childhood. The aim of the study was to evaluate the frequency of refractive errors in primary school children and their relationship with outdoor activity. Methods This croos-sectional study conducted with 4th grade primary school students in Eskisehir in 2023. Schools in the city center were divided into clusters according to their socio-economic status. Then, 1009 students from seven schools selected according to their randomization weights were included in the study. A questionnaire including sociodemographic characteristics, The Physical Activity Questionnaire for Older Children (PAQ-C) and questions about outdoor activities was administered to the students. They were examined for visual impairments. Outdoor activities were taken on weekdays and weekends and the daily average value was calculated. Results The mean age of the students was 9.8±0.5 years and 52.3% of them were female. Of 16.4% students had refractive errors, 5.85% had strabismus and 1.20% had depth perception deficits. Students with refractive error had lower scores on the PAQ-C scale and lower mean daily outdoor activity duration (p < 0.001 for each). In multivariate analysis, the risk of refractive error was found to be higher 4.61 times in those with good income (OR; 95%CI; 1.975; 10.75), 4.55 times in students who have visual impairment other than refractive error (OR; 95%CI; 3.01; 6.83), and 2.63 times (OR; 95%CI; 1.75; 3.95) in those who did outdoor activities for two hours or less a day. Conclusions Physical activity and outdoor activity duration were shorter in students with refractive errors. The risk of refractive error was found to be higher in those with good income, who have visual impairment other than refractive error, and those who did outdoor activities for two hours or less a day. Key messages • It is important to include regular screening programs on visual impairments and physical activity within school health studies. • In order to prevent the development or progression of refractive errors, children should be encouraged to engage in outdoor activities during the day.

Functions of collocations in the prevention of linguistic errors among Arabic learners as a foreign language

Functions of collocations in the prevention of linguistic errors among Arabic learners as a foreign language

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

The aim of this study was to determine prevented harm and cost avoidance following pharmacist intervention utilizing a discharge medication reconciliation tool. A retrospective chart review was conducted to identify patients with pharmacist-initiated, provider-accepted discharge medication reconciliation interventions completed at a community teaching hospital in January 2021. Investigators assigned the discrepancies targeted for intervention a National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) category, probability of harm, and calculated cost avoidance. The primary endpoint was the total cost avoidance associated with discharge medication reconciliation. Pharmacists intervened 190 times in January 2021, avoiding an estimated $46,958 to $231,032 in cost. High-risk medications were associated with $33,920 to $147,203 in cost avoidance. The 3 high-risk therapeutic classes associated with the highest cost avoidance were insulin ($16,738-$70,793), antithrombotics ($13,884-$60,016), and opioids ($2,638-$11,834). Targeted pharmacist discharge medication reconciliation and related interventions avoid significant cost and patient harm.

Efficacy of an error reporting-based education program on nursing students’ skill confidence, immersion, and satisfaction

The purpose of this study is to assess the impact of an innovative 'practice education program utilizing error reporting' on nursing students' immersion in practice, learning satisfaction, and confidence in executing fundamental nursing skills. Conducted over two days (November 28-29, 2022), this descriptive research engaged 110 second-year nursing students from a university in City S. The program, encompassing 24 sessions, each lasting an hour, culminated in debriefings and reflective exercises. Methodologically, the study employed an array of statistical tools, including independent t-tests, one-way ANOVA, Cheffe's test, Pearson's correlation coefficient, and multiple regression analysis. Key findings revealed a significant positive correlation between confidence in core nursing skill execution and practice immersion (r=.259, p=.006), as well as between practice immersion and learning satisfaction (r=.266, p=.005). Notably, practice immersion emerged as a pivotal factor influencing core nursing skill performance confidence (β=.272, p=.006), underscoring that heightened immersion positively impacts skill confidence. These insights suggest the need for ongoing program development, reinforced education, and heightened awareness around error prevention and reporting, to further augment nursing education outcomes.

Trust But Verify: Design Differences in The Prevention of Targeting Errors in Cephalomedullary Nails.

To evaluate insertional damage on explanted cephalomedullary nails and to differentiate typical from atypical wear to characterize outliers. Therapeutic. Level II trauma center. Patients who underwent removal of an implanted cephalomedullary nail for any reason from 2015 to 2023. Inspection of implants was performed at ×1000 magnification with a light microscope. Benchtop testing was performed with Gamma3, Gamma4, Intertan, TFN, and TFNa instrumentation. One hundred nine cephalomedullary nails were inspected. Insertional damage was observed in more than 95% of the implants recovered. In 34% (37 of 109) of implants, damage to the proximal aperture was severe enough to cause a chamfer or "notch." Chamfers were also encountered along the distal locking aperture in short stem implants in 44% (19 of 43). Guidewire chamfers to the proximal implant external to the aperture and damage to preinserted set screws were outliers. Evidence of set screw fracture or deformity was encountered in 12 specimens. Four anomalous set screw variants were encountered within 1 implant design, each variant exhibiting maltracking with deployment that could result in malfunction. Insertional damage to cephalomedullary implants was encountered routinely among the explants and should not always be categorized as preventable surgical error. Surgeons should be familiar with technical and design factors that contribute to chamfering of implants to reduce failures. Therapeutic, Level III.

Failures prevention methods for sustainability of production-failure modes and effect analysis in a business: a case study

Purpose- Quality activities should include all product life processes, starting from the determination of customers' demands and prejudices to the service activities provided to customers. By integrating quality-oriented practices, conducting FMEA, and employing Pareto analysis, the research aims to enhance the system's reliability, efficiency, and overall performance. This, in turn, can lead to improved customer satisfaction, reduced costs, increased productivity, and a more sustainable and successful operation in the packaging department. Methodology- In order to keep up with the rapidly developing technology, to be open to innovations with developing technologies, to be in an advantageous position against competitors and ultimately to satisfy customers and fulfil their satisfaction; it is necessary to meet the demands and needs of customers without error and at low cost. Failure Modes and Effect Analysis is applied to provide the sustainability of the production system without the failures. This study focuses on failure analysis, defining failure modes, and conducting error prevention studies within the context of businesses. The aim is to achieve zero failure and zero error by implementing effective prevention techniques. By identifying the root causes of failures and errors, businesses can develop strategies and procedures to prevent them from occurring in the first place. This proactive approach helps ensure a higher level of quality, reliability, and customer satisfaction. By emphasizing the importance of error and failure prevention, businesses can strive for continuous improvement, minimize disruptions in the production system, reduce costs associated with rework or product recalls, and maintain a strong competitive position. Implementing zero failure-error and zero error-failure prevention techniques is crucial for sustaining a reliable and efficient production system. Findings- This research shows that quality is a science that people meet in reality, not simply a theoretical concept. All organizations in the universe should take their quality management systems one step further with their approach to quality processes. In this context, the concept of zero failure-error in production or service lines has become important. By applying FMEA and considering sustainability aspects, the research aims to enhance the manufacturing process, minimize risks and failures, and contribute to sustainable practices in the food industry. Conclusion- The mentioned sample study on Failure Modes and Effects Analysis (FMEA) in food packaging within the production department of a food sector enterprise in the Marmara region highlights the importance of preventing possible failure modes and their impact on the sustainability of production. One key aspect emphasized in the study is the potential reduction of food and packaging waste by minimizing packaging or substituting oil-based materials with renewable resources. By utilizing environmentally friendly food packaging, various advantages can be achieved, including a decrease in food loss and waste, as well as a reduction in the negative environmental impact associated with managing packaging materials and waste. To accomplish this, it is crucial to address food demands throughout the entire food supply chain, with particular attention to transportation and consumption stages. In order to optimize the sustainability of food and packaging systems as a whole, it is necessary to consider the product and its packaging as an integrated system. By applying FMEA and considering the potential failure modes in food packaging, the study aims to identify areas for improvement and implement measures that enhance sustainability throughout the production process. Keywords: Failure prevention, failure mode and effect analysis, quality, sustainable production. JEL Codes: M10, L15, O14

Enhancing UI/UX of The Smart Village System Website Using User-Centered Design Methods

The Smart Village System is a platform specifically designed to help publicize village potential. Of course, it is very important to test UI/UX on sidespin websites which are still very far from perfect, so it becomes a question of whether the UI/UX sidespin is in line with the expectations of the community as the target user. This study intends to design UI/UX on sidespin websites by utilizing the UCD method which aims to improve interface quality, efficiency, and productivity as well as community satisfaction. The UI/UX design on this sidespin website uses the UCD method because several stages involve establishing a relationship and interaction between users. 5 people are willing to become User Personas who can provide input on user satisfaction which will be evaluated using a Heuristic Evaluation which will be combined with Survey Ratings. The results of this study state that all aspects of the satisfaction level of the User Persona are in the satisfied category. Recommendations were found to be developed by the Smart Village System Team, among others, in terms of the principles of Heuristic Evaluation 4, 5, and 6. Consistency and Standards have restructured sentences and are consistent from one page to another. Error Prevention has added many features to the sidespin and finally, Recognition rather than recall has implemented local and rural nuances on the page sidespin.

Translated article] Analysis of the degree of implementation of medication error prevention practices in Spanish hospitals (2022)

ObjectiveTo assess the degree of implementation of medication error prevention practices in Spanish hospitals. MethodDescriptive multicenter study of the degree of implementation of the safety practices included in the “Medication use-system safety self-assessment for hospitals. Version. II”. Spanish hospitals that completed the questionnaire between October, 2021 and September, 2022 participated. The survey contains 265 items for evaluation grouped into 10 key elements. Mean score and mean percentages based on the maximum possible values for the overall survey, for the key elements, and for each individual item of evaluation were calculated. The results were compared with those of the previous 2011 study. ResultsA total of 131 hospitals from 15 autonomous regions participated in the study. The mean score of the overall questionnaire in all hospitals was 898.2 (57.4% of the maximum possible score). No differences were found according to dependency, size, or type of hospital, either in the overall questionnaire or in the key elements. The lowest values were found for key elements VIII, I and VI, on competence and training of health professionals in safety practices (45.1%), availability and accessibility of essential information on patients (48%), and devices for administering drugs (52.3%). With respect to 2011, significant increases were found both in the overall questionnaire and in the key elements, except V and VII, referring to standardization, storage, and distribution of medications, and environmental factors and human resources. Several evaluation items on the safe management of high-risk drugs, medication reconciliation, incorporation of clinical pharmacists into the healthcare teams, and implementation of technologies that allow full traceability throughout the medication system, showed low percentages. ConclusionsThere has been appreciable progress in the degree of implementation of some medication error prevention practices in Spanish hospitals, but many proven efficacy practices recommended by the World Health Organization and safety organizations are still poorly implemented. The information obtained can be useful for prioritizing the practices to be addressed and as a new baseline for monitoring progress.

Análisis del grado de implantación de las prácticas de prevención de errores de medicación en los hospitales españoles (2022)

ObjectiveTo assess the degree of implementation of medication error prevention practices in Spanish hospitals. MethodDescriptive multicenter study of the degree of implementation of the safety practices included in the "Medication use-system safety self-assessment for hospitals. Version. II". Spanish hospitals that completed the questionnaire between October/2021 and September/2022 participated. The survey contains 265 items for evaluation grouped into 10 key elements. Mean score and mean percentages based on the maximum possible values for the overall survey, for the key elements and for each individual item of evaluation were calculated. The results were compared with those of the previous 2011 study. ResultsA total of 131 hospitals from 15 autonomous regions participated in the study. The mean score of the overall questionnaire in all hospitals was 898.2 (57.4% of the maximum possible score). No differences were found according to dependency, size or type of hospital, either in the overall questionnaire or in the key elements. The lowest values were found for key elements 8, 1 and 6, on competence and training of health professionals in safety practices (45.1%), availability and accessibility of essential information on patients (48%), and devices for administering drugs (52.3%). With respect to 2011, significant increases were found both in the overall questionnaire and in the key elements, except 5 and 7, referring to standardization, storage and distribution of medications, and environmental factors and human resources. Several evaluation items on the safe management of high-risk drugs, medication reconciliation, incorporation of clinical pharmacists into the healthcare teams and implementation of technologies that allow full traceability throughout the medication system, showed low percentages ConclusionsThere has been appreciable progress in the degree of implementation of some medication error prevention practices in Spanish hospitals, but many proven efficacy practices recommended by the World Health Organization and safety organizations are still poorly implemented. The information obtained can be useful for prioritizing the practices to be addressed and as a new baseline for monitoring progress.

ANALYSIS OF USABILITY USING HEURISTIC EVALUATION METHOD AND MEASUREMENT OF SUS ON PRICILIA APPLICATION

The Presence Digital Application (PRICILIA) is a presence application owned by PT. BGR Logistics Indonesia. However, until now, there has never been an evaluation of usability testing. Complaints from users regarding the PRICILIA application include menu displays that are less interactive, long loading times, and the unavailability of other alternatives besides GPS. Of course, this affects the level of user satisfaction with the application. Therefore, usability testing is needed to be able to measure the level of user comfort, application feasibility, and the application interface. In this study, the system evaluation method used is Heuristic Evaluation with measurement using the System Usability Scale (SUS). The results of this study indicate that aspects that need to be improved with high priority are Error Prevention (H5) and Recognition rather than Recall (H6) because they have a seriousness rating on a scale of 3, while the average score of the final seriousness rating obtained from a total of 10 heuristic aspects is 1, 72 which is then rounded off to a scale of 2. The SUS test results obtained an average final SUS score of 55.13. The results of the calculation of the SUS method are that the Acceptance Ranges have low marginal status, the Grade Scale is on a D scale, and the Adjective Twigs are at the OK level. This shows that the PRICILIA application still needs improvement. Therefore, 30 recommendations for improvement are proposed for future application development.

A-192 Cause and Departmental Origin of Errors—An Investigation of Questionable Patient Test Results

Abstract Introduction Reliable patient test results are crucial for quality patient care, involving pre-, post- and analytical phases. Questionable Patient test Results (QPRs), either not matching patient clinical presentation or apparent outliers for the patient population, are often encountered. We aimed to investigate the source and nature of possible errors that cause QPRs. Methods 960 QPRs were identified during July-December 2022 at our institution. We examined the nature of the QPRs, the corresponding patient clinical records, the procedures involved in pre-, post- and analytical phases, and quality control systems. Results The QPRs were found to be originated from 31 departments and medical specialty units. Of those, 5 departments/units had >50 QPRs (accounting for 64% of total QPRs) and are listed in the table provided. The table also lists the information on 7 types of errors identified by our analysis. Of all errors, 78% occurred at pre-analytical phase, with the majority of errors occurring during sample collection. Discussion The most common types of errors were either diluted or contaminated samples accounting for 38% and 34%, respectively. Such errors often occur during sample drawing from an existing I.V. access port if not adequately flushed after saline solution infusion (causing sample dilution) or dextrose solution (causing glucose contamination). Many errors were due to samples drawn in the wrong collection tube type. Sample integrity issues included hemolysis, lack of sufficient sample volume, or clotting. For those QPRs that we did not find apparent errors, they were either due to random errors or the results fit the patient’s true medical condition. Conclusions Our findings highlight the importance of pre-analytical quality control measures and the need for regular staff education/training. This study pinpointed the errors that require targeted education materials, as well as the hospital units that would benefit most from this focus on error prevention.

What Do We Know About Patient Safety Culture in Saudi Arabia? A Descriptive Study.

Patient safety is described as the prevention and mitigation of medical errors that can result in harm while a patient is receiving care. One important way to improve safety is through improving the patient safety culture in healthcare. The purposes of this study are to evaluate the patient safety culture trend in Saudi Arabia and assess the improvement over time. This study is a descriptive study that used a retrospective analysis of a national data set for 3 cycles from 2019 to 2022. To generate a baseline and allow comparison of the hospital's survey results with the aggregated findings from the database, the 10th, 25th, 50th, 75th, and 90th percentiles were calculated to set the percentage of values. Our results found that one of the barriers to developing a strong patient safety culture in Saudi Arabia is management support of patient safety, which caused a blame culture. This could explain the absence of improvement in the average percentage of reporting patient safety events for all 3 cycles. On the other hand, a decrease was observed in organizational learning/continuous improvement as well as a reduction in the positive percentage of patient safety ratings in the last cycle. Moreover, areas of strength in all 3 cycles did not reach the 75th percentile, whereas staffing and response to error domains remained the lowest-scoring composites in all cycles. Our results have determined the percentile of the positive rate that could guide hospitals to improve their culture survey results. More investigations can focus on change over the years in both patient safety culture and the effectiveness of implementing interventions to measure the impact on quality of care.

Knowledge, attitude regarding prevention of medication errors among registered nurses

Background: Medication error (ME) is a preventable incident that might lead to patient harm or cause inappropriate medication use while the patient, healthcare professional, or consumer controls the medication. Such incidents might be related to the procedures and systems, including pre-labelling order communication, product labelling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use, professional practice and health care products. According to World Health Organization (2016), 6-7% of inpatients are exposed to medication errors daily, mostly admitted to the intensive care unit (ICU) and long-term care. Medication errors could result in negative events affecting patient safety, such as adverse events causing disability, injury and even in-hospital death.Purpose: To assess the knowledge regarding the prevention of medication errors and the attitude regarding the prevention of medication errors among registered nurses in a private hospital, particularly in Sarawak.Method: A descriptive quantitative research design cross-sectional survey has been chosen. A set of questionnaires adapted from Di Simone et al. (2018) about knowledge on the administration of IV drugs and attitude, while knowledge on serving medications was adapted from Johari et al. (2013), has been distributed to 122 registered nurses of the private hospital to obtain information about the nurses' knowledge and attitude on the prevention of medication error. The data has been analyzed using the IBM Statistical Package for Science (SPSS) version 20. In this study, a purposive sampling method has been used to enrol eligible participants. Participants’ knowledge and attitude were analyzed using frequency and percentage. The Pearson correlation coefficient test has been used to determine the relationship between knowledge and the socio-demographic data among registered nurses in a private hospital.Results:The study revealed that most of the registered nurses, 93 (76.2%) in one of the private hospitals in Sarawak, East Malaysia, have moderate knowledge of serving medications and a strong correlation between the level of education and knowledge regarding preventing medication error.Conclusion: Nurses have moderate knowledge and positive attitudes in preventing medication errors.

Safe handoff practices and improvement of communication in different paediatric settings

Inadequate information management, especially during patient handoff, contributes to a large part of health care-related adverse events. The Committee for Quality of Care and Patient Safety of the Asociación Española de Pediatría has developed this document to provide an overview of handover practices in different paediatric care settings (emergency, inpatient, intensive care, neonatal and primary care). It describes resources to achieve safe and effective communication in all these settings, such as standardised handoff tools. It also proposes recommendations for the prevention of medication errors during the handover process, to improve safety in interhospital and intrahospital patient transfer, and to optimise communication and continuity of care in chronically ill and medically complex children.

Error orientation in a decision-making simulation program: differences between promotion vs. prevention focus.

Changing situations develop work environments where workers must generate strategies to learn and persist from continuous errors and setbacks. Previous research has shown that errors enhance motivation, break the routine, lead to creative solutions, and reduce frustration; however, this positive aspect seems to have a stronger presence if personal factors and contextual background support such a focus. The main aim of this paper was to analyse, with an experimental design, how different frames about errors and negative feedback (error promotion versus error prevention) affected performance and decision-making processes in a complex simulation task, taking into account individual attitude towards errors. The sample included 40 employees of a Spanish transportation company (37.5% were women and 62.5% were men). Firstly, participants answered a questionnaire about their individual Error Orientation. Then, they were randomly assigned to an experimental condition to carry out a complex decision-making task through a multimedia simulator, which aimed to expose the participant to factors that influence the dynamics of innovation and change, elements that are present in all modern organizations. None of the participants had previous experience in the task. Performance was measured through different aspects: (1) final performance values: adopters, points, time to make decisions and time after receiving negative feedback; (2) the decision-making process. Results showed that error orientation is related to final performance, especially error risk taking and error communication. The effect of the experimental condition was higher for the time to make decisions after receiving negative feedback and for the time to complete the simulation program. Those who worked under the error prevention condition took significantly longer to perform the task. Although our results show non-consistent effects, which frame than the other (promotion versus prevention) is better to make decisions is discussed. A promotion frame prioritizes flexibility, openness, and rapid progress, but does so by sacrificing certainty, and careful analysis. The most crucial factor may be which one best fits the demands of the task at hand.

Patient safety improvement in the gastroenterology department: An action research.

Patient safety is a global concern. Safe and effective care can shorten hospital stays and prevent or minimize unintentional harm to patients. Therefore, it is necessary to continuously monitor and improve patient safety in all medical environments. This study is aimed at improving patient safety in gastroenterology departments. The study was carried out as action research. The participants were patients, nurses and doctors of the gastroenterology department of Ayatollah Taleghani Hospital in Tehran in 2021-2022. Data were collected using questionnaires (medication adherence tool, patient education effectiveness evaluation checklist, and medication evidence-based checklist), individual interviews and focus groups. The quantitative data analysis was done using SPSS (v.20) and qualitative data analysis was done through content analysis method using MAXQDA analytic pro 2022 software. The majority of errors were related to medication and the patient's fault due to their lack of education and prevention strategy were active supervision, modification of clinical processes, improvement of patient education, and promotion of error reporting culture. The findings of the research showed that the presence of an active supervisor led to the identification and prevention of more errors (P<0.01). Regarding the improvement of clinical processes, elimination of reworks can increase satisfaction in nurses (P<0.01). In terms of patient education, the difference was not statistically significant (P>0.01); however, the mean medication adherence score was significantly different (P<0.01). The improvement strategies of patient safety in Gastroenterology department included the modification of ward monitoring processes, improving/modification clinical processes, improvement of patient education, and development of error reporting culture. Identifying inappropriate processes and adjusting them based on the opinion of the stakeholders, proper patient education regarding self-care, careful monitoring using appropriate checklists, and presence of a supervisor in the departments can be effective in reducing the incidence rate. A comprehensive error reporting program provides an opportunity for employees to report errors.