Journal of Ergonomics

Background and Objectives: Human errors in dialysis care can cause injury and death. One of the basic steps to increase reliability in this critical process is to analyze the error and identify the weaknesses of doing this process.
Methods: The present study is a descriptive-analytic cross-sectional study. The SPAR-H method was used to identify and evaluate the probability of human error in the dialysis process. The hospital had six dialysis department and 16 dialysis machines with two nurses in each department. Data collection was done by observing the dialysis process, interview with nurses, reviewing the documents, methods of work and work instructions.
Results: The present study showed that the probability of human error in the duties of a dialysis nurse is in the range of 0.02-0.44 (except for devices related to disorder), which is related to sub-duty preparing patient as lowest rate and sub-duty of the pump set-off as highest error rate.
Conclusion: To reduce and control the human error in nursing duties in the dialysis department, control measures should be done such as increasing the number of personnel, changing the time shift of nurses, and training, preparing and revising the instructions.