SULM – Schweizerische Union für Labormedizin | Union Suisse de Médecine de Laboratoire | Swiss Union of Laboratory Medicine

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R. Urbinelli 1 , B. Hauri 2 , M. Goetzmann 2 , A. R. Huber 1

1Laboratory Medicine, Kantonsspital Aarau, Switzerland , 2H-Informatik, Aarau, Switzerland

Objective: Critical Incident Reporting System have been successfully used since many years in aviation and industries. Interestingly, implementation of this tool in medicine has not taken place until most recently with Anaesthesia and Paediatrics being the first to use CIRS as additional quality assurance (QAC) tool. In order to further improve our existing QAC and knowing that near misses occur by fare more frequent than serious incidents, we have developed and implemented a computer based CIRS that would fulfilled the needs of a large laboratory. Methods: The basic causes of incidents are located at the very beginning of the chain of events, and may be Technical, Organisational, Human Operator Failures, or most likely a combination of these. The CIRS follows the principle of the Deming cycle. All team members were encouraged to anonymously report in a data base near misses of any kind. An easy to use form was developed and placed on the hospital intranet. Several categories were created including causes, time, circumstances and potential effects on patients. The observation period was 24 month with teaching, evaluation and feedback every 3 month. Results: In a lab with a test volume of approximately 200'000/month it is expected that mishaps and errors occur. In 51% of the reported cases inattention without sleep deficit was recorded, in 15% massive workload, in 21% typing or entering errors and in 9% non-compliance with SOP’s was indicated as the cause. 57% were near misses (detected before the result left the laboratory). Conclusion: Routine collection of data on mishaps in a laboratory allow for detailed analysis of causes and help improving an existing QAC including targeted training, SOP’s modification and give lessons for high-risk domains. Prerequisites for successful implementation of a CIRS are anonymity, simplicity of the system and an environment of trust free of repressions including legal action against data entering personnel.

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