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Evaluation of human errors using Standardized Plant Analysis Risk among health provider personnel in a hospital in Qazvin Province in 2016-2017

  • Mohammad Reza Moddaber ,
  • Batoul Ahmadi ,
  • Ali Mohammad Mosadeghrad ,


Background: Human error in the health industry that deals with the lives of people can lead to irreparable losses and massive costs.

Aim: The current study aimed at identifying and evaluating human errors using the SPAR-H technique in one of the hospitals in Qazvin Province.

Method: This study was a cross-sectional study that was conducted in one of the training hospitals of Qazvin in 2016-2017. The target community was 49 of the most senior personnel in four groups of nursing, laboratory, radiology, and services. At first, task analysis was conducted to target group using Hierarchical Task Analysis (HTA) technique by Focus Group method. In the next step, the Human Error Probability (HEP) was determined to utilize SPAR-H method and of performance-shaping factors (PSFs) and action and diagnosis activities were identified. Finally, after determining the dependency level, the final diagnosis HEP was calculated.

Result: Of the total tasks and errors identified, 9 tasks and 17 errors were related to the activities of the nursing staff, 5 assignments and 17 errors related to the activities of the laboratory experts, 3 tasks and 5 errors related to the activities of radiology experts and 3 tasks and 6 errors related to the activities of the service.

Conclusion: The analysis of errors identified in this study showed that the major causes of errors due to the high volume of work and insufficient time in all target groups could be attributed to shortage of available time, stress and high work pressure of personnel.


  1. Kllberg AS, GÙransson KE, stergren J, et al. Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff and patients – a national review. Eur J Emerg Med. 2013;20(1):33–38.
  2. Guillod O. Medical error disclosure and patient safety: legal aspects. Journal of Public Health Research. 2013;2(3): 31–185.
  3. Akbari Sari A B, et al. Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. Qual Saf Health Care 2007:16. pp:434–439
  4. Soop M, et al. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. International Journal for Quality in Health Care 2009: 21 (4). pp: 285–291.
  5. Makar, MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016; 535: 1-5.
  6. Van Den Bos J. Rustagi K. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Affairs. 2011; 30(4): 596-603.
  7. James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J Patient Saf. 2013;9(3):122-8. doi: 10.1097/PTS.0b013e3182948a69.
  8. John A. Forester S E C, Alan M, Czkowski K, Bley DC, Wreathall E L J. "An Overview of the Evolution of Human Reliability Analysis in the Context of Probabilistic Risk Assessment." Sandia National Laboratories, United States Department of Energy’s National Nuclear Security Administration. 2009
  9. Robinson Wolf Z, Hughes R G. Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Agency for Healthcare Research and Quality. U.S. Department of Health and Human Services. April 2008. Vol 2. pp: 333-379.
  10. Davis RE, Sevdalis N, Neale G, et al. Hospital patients’ reports of medical errors and undesirable events in their health care. J Eval Clin Pract. 2013;19(5):875–881.
  11. Kusler-Jensen J WAJ. FMEA An idea whose time has come. SSM. 2003 Jun; 9(3):30.
  12. Zarr Nezhad A, Jabbari M, Keshavarzi M. Identification of the Human Errors in Control Room Case Operators by Application of HEIST Method(Case Study in an Oil Company (Persian) 2013.
  13. Mohamadfam I, Nikomaram H, Yoosef H, Pirhadi M. Assessment and management of human errors in emergency situations by HEPI method (case study: a Manufacturing industry). Jundishapur Journal of Health Sciences. 2012; 4(4):47-57.
  14. Salmon P, Stanton N, Walker G. Human Factors Design Methods Review Authors [Online]. 2003 [cited 2003 Nov 28]; Available from: URL:
  15. Mazlomi A, Hamzeiyan M, Dadkhah A, Jahangiri M, Mohadesi P. Assessment of Human Errors in an Industrial Petrochemical Control Room using the CREAM Method with a Cognitive Ergonomics Approach. Scientific Journal of School of Public Health and Institute of Public Health Research. 2011; 8(4):15-30.
  16. Meng, Z., Vladislav K., Dragan K. Investigation of haul truck-related fatal accidents in surface mining using fault tree analysis, Safety Science, 2014; 65(2): 106-117.
  17. Gertman DI, Blackman HS, Marble J, Byers J, Smith C. The SPAR-H human reliability analysis method: US Nuclear Regulatory Commission; 2005.
  18. Kohn LT, Corrigan JM, Donaldson MS." To Err Is Human: Building a Safer Health Care System." Washington, DC: Institute of Medicine. 1999.
  19. Baker GR, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. JAMC. 25 MAI 2004: 170 (11).
  20. Tanha F, Mazloumi A, Faraji V, Kazemi Z, Shoghi M. Evaluation of Human Errors Using Standardized Plant Analysis Risk Human Reliability Analysis Technique among Delivery Emergency Nurses in a Hospital Affiliated to Tehran University of Medical Sciences. JHOSP. 2015; 14 (3) :57-66.
  21. Ghaffari F, Rasoulzadeh Y, Asghari Jafarabadi M, Dianat I. The variety and rate of human error in reception staff of clinical laboratories in Tehran and Tabriz in 2014. Iran Occupational Health 2016; 12) 6(:28-38.
  22. Shepherd A. HTA as a framework for task analysis. Ergonomics. 1998; 41(11):1537-52.
  23. Gertman DI, Blackman HS, Marble J, Byers J, Smith C. The SPAR-H human reliability analysis method: US Nuclear Regulatory Commission; 2005.
  24. Bell J, Holroyd J. Review of human reliability assessment methods. Health & Safety Laboratory. 2009.
  25. Ferdowsi M, Ghoveood A, Nemati A, Sha'bani N, Hosseinzadeh E. Prevalence of voluntary reporting of medical errors in hospitals of Mazandaran University of Medical Sciences in 2014. Manage Strat Health Syst 2016; 1(1): 61-69.
  26. Mohammad Ghasemi, Amir Hossein Khoshakhlagh, Sadrollah Mahmudi & Mohammad Gholami Fesharaki (2015) Identification and assessment of medical errors in the triage area of an educational hospital using the SHERPA technique in Iran, International Journal of Occupational Safety and Ergonomics.2015; 21:3, 382-390.DOI: 10.1080/10803548.2015.1073431.
  27. Ehsani R, Cheraghi MA, Nejati A, Salari A, Haji Esmaeilpoor A, Mohammad Nejad E. Medication errors of nurses in the emergency department. J Med Ethics Hist Med 2013; 6(11): 1-7.
  28. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006; 34(2): 415-25.
  29. Desai RJ, Williams CE, Greene SB, et al. Exploratory evaluation of medication classes most commonly involved in nursing home errors. J Am Med Dir Assoc. 2013;14(6): 403–408.
  30. Manias E, Kinney S, Cranswick N, et al. Medication errors in hospitalized children. J Paediatr Child Health. 2014;50(1):71–77.
  31. Bagheri-Nesami M, Esmaeili R, Tajari M. Frequency of Non-Injectable Medication Administration Errors in Nurses of Cardiac Critical Care Units in Mazandaran Province in 2014. J RafsanjanUniv Med Sci 2016;15(2): 151-64.
  32. Rasoulzadeh Y, ghaffari F, Asghari Jafarabadi M, Dianat I. The variety and rate of human error in reception staff of clinical laboratories in Tehran and Tabriz, 2014. ioh. 2016; 12 (6) :28-38 URL:
  33. Bela P. FMEA: A model for reducing medical errors. Clin Chem Acta. 2009; 404: 75–78.
  34. Chawla R, Goswami B, Tayal D, Mallika V. Identification of the Types of Preanalytical Errors in the Clinical Chemistry Laboratory. Department of Biochemistry. Pant Hospital, New Delhi, India. 2009.
  35. Carraro P, Plebani M. Errors in a statlaboratory: Types and frequencies 10 years later. Clin Chem. 2007; 53: 1338–1342.
  36. Shashi U, Sanjay U, Rani B, Nadia J, Vinay B. Types and Frequency of reanalytical Errors in Haematology Lab. Journal of Clinical and Diagnostic Research. 2013.

How to Cite

Moddaber, M. R., Ahmadi, B., & Mosadeghrad, A. M. (2019). Evaluation of human errors using Standardized Plant Analysis Risk among health provider personnel in a hospital in Qazvin Province in 2016-2017. Bali Medical Journal, 8(1), 233–240.




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Mohammad Reza Moddaber
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BMJ Journal

Batoul Ahmadi
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BMJ Journal

Ali Mohammad Mosadeghrad
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BMJ Journal