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Near-miss errors in laboratory blood test requests by interns
K M Chow1, C C Szeto, M H M Chan
1Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. chow_kai_ming@alumni.cuhk.net
QJM : Monthly Journal of the Association of Physicians
|August 30, 2005
Summary
The first month of medical internship is a high-risk period for near-miss errors in laboratory blood test requests. Interventions are needed to improve patient safety during this critical training phase.
Area of Science:
- Medical error analysis
- Patient safety research
- Healthcare quality improvement
Background:
- Human errors are a significant challenge in acute hospital care.
- Near-miss events in laboratory blood test requests pose a risk to patient safety.
Purpose of the Study:
- To identify the at-risk period for near-miss errors in laboratory blood test requests.
- To analyze factors contributing to these errors in an acute medical hospital.
Main Methods:
- Retrospective analysis of voluntary near-miss error reports.
- Data collected from 104 medical interns over a 2-year period.
- Analysis of errors based on months of experience, work hours, and shifts.
Main Results:
- The incidence of near-miss events was significantly higher during the first month of internship (1.6 cases/100 intern-days) compared to subsequent months (0.6 cases/100 intern-days).
- The odds ratio for a near-miss event was 2.64 during the first month versus later months.
- Near-miss events peaked during extended on-call shifts, particularly after 12-20 hours of work.
Conclusions:
- The initial month of internship is a critical period for near-miss errors.
- Further research is required to develop effective interventions for reducing errors by new medical interns.