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Eye surgeries are very sensitive to human errors that can reduce the patient's safety and cause irreparable damage. This study will show where and why human errors occur during eye surgery and minimize them. This study was conducted to demonstrate the feasibility of using a simple and practical technique for analyzing the process of eye surgeries to identify opportunities for managing human error. The basis of this study is the analysis of strabismus surgery and related processes (such as patient anesthesia and postoperative recovery) using the HTA and the identification and evaluation of probable human errors in the tasks and sub-tasks using the SHERPA technique. The activities were divided into 83 tasks and sub-tasks. Investigations of the findings of HTA resulted in the identification of 58 probable errors. Action errors with a prevalence rate of 64% had the highest frequency, followed by checking, retrieval, and selection errors with 17%, 12%, and 7%, respectively. Based on the results, 5% of the errors were at the unacceptable risk level, 50% at undesirable risk level, 31% at acceptable risk level but with revision requirements, and 14% at acceptable risk level without the need for revision. This study showed that the use of human reliability analysis methods in eye surgeries can have major advantages such as: identifying the areas with the highest probability of error, prioritizing error by determining the level of risk or probability of their occurrence and providing appropriate control solutions to minimize the risk of error.

Application of SHERPA technique in ophthalmic operating rooms to identify and evaluate human errors: a case study of strabismus surgery process