Abstract
According to the report of Joint Commission of Taiwan, the top five patient safety incidents in Taiwan are medication errors, patient fall events, tube incidences, injury behavior events, an inspection events. The factors of patients are mainly due to the behavior of subjective consciousness, so it is difficult to be controlled effectively. Besides, medication errors have been widely studied and improved in the past. Therefore, this study focuses on the inspection events, so as to reduce human error and enhance patient safety. A total of 16 medical technologists in a regional teaching hospital in Hsinchu were surveyed for their inspection work associated with Hematology in laboratory medicine. The operating processes were observed and recorded by a digital video recorder. After that, according to the records of test reports issued in 2014 and 2015, the most frequent causes of report correction were identified, followed by Root Cause Analysis (RCA) for potential strategies of improvement. On the other hand, the Healthcare Failure Mode and Effect Analysis (HFMEA) was carried out for prospective risk management, which helps formulate improvements according to the action priority of the potential failure modes. Moreover, the relationship between medical technologists’ workload and operations was evaluated by using NASA Task Load Index. The results of current status analysis showed that there was no monthly trend found in numbers of report correction. Besides, the major reasons for report correction are "inspection procedure error," "result input error," and "result identification error." After that, the most frequent cause of report correction was analyzed by Root Cause Analysis. The result of RCA indicated that unclear instructions of when to change the reagent may lead to report correction, which needs engineering improvement. In addition, the result of HFMEA showed that there were three failure modes requiring improvement, including" lipaemic samples being delivered by pneumatic tube system," " sample clot," and " the aperture of coulter counter being blocked." Thus, the improvement for each failure mode was proposed and evaluated through expert opinions. According to the results of medical technologists’ subjective workload, "Blood film" and "Body fluid" had the highest workload, while "Erythrocyte sedimentation rate" and "Hemoglobin electrophoresis" had the lowest workload. It can be inferred that medical technologists’ workload increases with manual tasks. In addition, there was no significant difference in workload between male and female medical technologists. But when it comes to work experience and work shift, senior medical technologists’ workload are higher than junior ones, while those on day shift are with higher workload than those on night shift. Further, it was found that as the number of operating steps increases, the workload becomes higher. However, work processes with higher risks are not always accompanied with a higher workload. Moreover, larger number of report correction was not found in work processes with higher workload. Thus workload may not be a direct cause of the report correction. The overall results of current status analysis, HFMEA, RCA and NASA Task Load Index showed that the reason for report correction is not directly related to the risks and workload of work processes. In order to effectively respond to the frequent causes of report correction, further studies applying other analyzing tools is therefore suggested. However, the analysis results of this study did help identify improvement strategies to prevent human errors. Besides, since this study was limited to Hematology in laboratory medicine, further studies regarding other work groups would be worthwhile for a broader range of clinical improvement.