OBJECTIVE: Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care. MATERIAL AND METHODS: All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire. RESULTS: Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff. CONCLUSIONS: The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.
OBJECTIVE: Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care. MATERIAL AND METHODS: All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire. RESULTS: Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff. CONCLUSIONS: The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.
Authors: Stephanie Archer; Louise Hull; Tayana Soukup; Erik Mayer; Thanos Athanasiou; Nick Sevdalis; Ara Darzi Journal: BMJ Open Date: 2017-12-27 Impact factor: 2.692