Near-miss errors in laboratory blood test requests by interns.
BACKGROUND
Human errors have proven to be one of the most formidable patient care challenges in acute hospital setting.


OBJECTIVE
To evaluate the at-risk period for near-miss errors in laboratory blood test requests, in an acute medical hospital.


METHODS
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.


CONCLUSIONS
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.
Chow
K M
KM
Department 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
Szeto
C C
CC
Chan
M H M
MH
Lui
S F
SF
D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care; D005260:Female; D006403:Hematologic Tests; D006723:Hong Kong; D006801:Humans; D007396:Internship and Residency; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital / Q000592:standards; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies