Incident reporting practices in the preanalytical phase: Low reported frequencies in the primary health care setting

Abstract

Objective: Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care. Material and methods: All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire. Results: Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff. Conclusions: The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.

Key Words::

• Blood specimen collection
• medical errors
• phlebotomy
• quality of health care
• questionnaires

Acknowledgements

We would like to thank the National Board of Health and Welfare in Sweden, the Faculty of Medicine, Umeå University, Umeå, Sweden and Västerbotten County Council in Sweden, for research funding.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.