QJM Advance Access originally published online on August 26, 2005
QJM 2005 98(10):753-756; doi:10.1093/qjmed/hci116
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Near-miss errors in laboratory blood test requests by interns
From the Departments of 1Medicine & Therapeutics and 2Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China
Address correspondence to Dr K.M. Chow, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. email: chow_kai_ming{at}alumni.cuhk.net
Received 11 May 2005 and in revised form 13 July 2005
Background: Human errors have proven to be one of the most formidable patient care challenges in acute hospital setting.
Aim: To evaluate the at-risk period for near-miss errors in laboratory blood test requests, in an acute medical hospital.
Design: Hospital-based retrospective analysis.
Methods: We reviewed the database of voluntary reports for near-miss errors for laboratory blood test requests by 104 medical residents in their first postgraduate year (interns), over a 2-year period (October 2002 to September 2004). To identify patterns and causal factors we analysed the reports with respect to months of working experience, work hours, and work shifts of an extended duration.
Results: There were 52 near-miss events among patients cared for by the medical service (20 male patients, 32 females, mean age 72.6 ± 9.7 years). The overall incidence of near-miss events when interns practiced during the first month of training vs. subsequent months was 1.6 (95%CI 0.77–2.9) vs. 0.6 (95%CI 0.44–0.83) cases per 100 intern-days at risk. The odds ratio for a near-miss event during the first month of intern training vs. subsequent months was 2.64 (95%CI 1.29–5.38). With respect to the interns’ on-call shift schedule, one half of the near-miss episodes occurred during an intern's on-call days and another half of them during an extended on-call shift; none of the events occurred during a standard working shift. These events peaked in frequency when on-call interns had worked for 12–20 h.
Discussion: The first month of internship represents an error-prone period. The best interventions to reduce near-miss errors by recently graduated medical interns should be the subject of further research.