Evaluation of Human Errors in Nurses by Standardized Plant Analysis Risk Technique

This research was conducted with the aim of evaluating human errors among nurses in three hospital wards including emergency, emergency delivery, and cardiac care wards in one of the hospitals of Ahwaz University of Medical Sciences to eliminate or reduce the human errors of nurses and promote the health and safety of patients through recognition of potential.and obvious human errors.

The present applied and cross-sectional study was conducted among all 54 nurses in three wards of a hospital. The data were collected using direct observation of the activities of nurses and supervisors in each ward. After hierarchical analysis of the tasks, human errors were identified and evaluated using standardized plant analysis risk-human (SPAR-H) technique and the worksheets were completed. In the last step, the level of risk was evaluated using the probability and severity of the error.

Injection of blood products has the highest percentage of human errors (74.3%) in the emergency ward. The highest percentages of human errors in the cardiac care unit ere related to duties such as giving injectable drugs (74.3%), blood and its products transfusion (74.3%), and announcement of code and initiation of cardiopulmonary resuscitation (67.8%). Higher probability of human errors in the emergency ward were observed in the receiving drug orders (32.8%) and completing the drug orders (57.1%) which are the main tasks of nurses in this ward. In the delivery emergency ward, blood transfusion had the highest percentage of human errors (74.3%).

The main identified human errors in this study were drug errors, errors related to the transfusion of blood products, and the maintenance of equipment and data storage errors. The main cause of these errors are shortage of time, irregular working shifts, and the limitations and defects in experience and education.