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QJM Advance Access published online on August 26, 2005
QJM, doi:10.1093/qjmed/hci116
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© The Author 2005. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Received May 11, 2005
Revised July 13, 2005

Original paper

Near-miss errors in laboratory blood test requests by interns

K.M. Chow 1*, C.C. Szeto 1, M.H.M. Chan 2, and S.F. Lui 1

1 From the Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China
2 From the Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China

* To whom correspondence should be addressed.
K.M. Chow, E-mail: chow_kai_ming{at}alumni.cuhk.net


  Abstract

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.


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