شناسایی و ارزیابی خطاهای انسانی در اعمال جراحی چشمی با استفاده از روش PHEA

ntroduction: In all over the world, one of the major problems in health care is medical errors, causing physical and psychological complications for patients, family and even the community. So, identification and assessment of human errors’ probability and their consequences in eye surgeries was the aim of this study. Methods: This cross-sectional study was performed using PHEA technique. First, the goals and results of the research were fully explained to the surgeons and the operating room personnel, then, thorough direct observations of various eye surgeries, based on the analytical hierarchy technique (HTA), documentary registrations and interviews with the subjects were done; the hierarchical chart of the personnel and surgeons occupational tasks were arranged. Then, the standard worksheets for the PHEA technique filled out by the research team. Results: Generally, 68 tasks and 187 sub tasks were identified and probable human error for them was 58%. A total of 132 error codes, including functional errors (67.42%), checking errors (14.39%), retrieval errors (5.31%), selection errors (9.1%), and communication errors (3.78%) were identified; any program error code was not detected. The highest percentage of errors was related to performance errors and the least to communication and program errors. Conclusion: Results show that in many of studies on medical errors, as well as the present one, the incidence of human errors in eye surgery is high and in some cases there are very unpleasant consequences; and since, the most detected errors are of functional type. So, it should be prioritized in order to control and reduce medical errors.