تحلیل علل ریشه‌ای خطا در تشخیص آلودگی میکروبی بخش‌ مراقبت‌های ویژه یک بیمارستان منتخب دانشگاه علوم پزشکی تهران و ارائه راهکار مناسب با استفاده از تکنیک دلفی

Background: microbial contamination of hospital wards is one of the most important factors in the transmission of hospital infections among inpatients in hospital units. This study aimed to analyze the error in the diagnosis of microbial contamination in the hospital's intensive care unit and its root causes analysis in 2015.   Materials and Methods: This study was conducted in three stages. The first stage conducted as a case report. The second stage was designed to identify the factors affecting the occurrence of error by Root Causes Analysis and conducting an interview and panel. Third stage was provided using self-made questionnaire and Delphi technique to obtain appropriate strategies to identified errors. In order to data analysis SPSS software was utilized.   Results: The main causes of hospital infections were organizational and managerial causes, task related causes, laboratory-related causes, causes associated with training, causes associated with work teams and causes related to working conditions in the intensive care unit. The study findings extracted from the Delphi technique revealed that simple actions such as hand wash and disposable appliances usage are significantly effective in hospital infection prevention.   Conclusion: One of the most important ways of preventing and controlling hospital infections is investigating the root causes of these infections. Also, personnel training regarding effective methods to nosocomial infections’ care and control and patient safety culture should be considered by managers.