System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model.
Bottom Line: The most frequently occurring hazard was the inadequate process for matching test requests and results received (n=350, 54.1%).Of the 1604 instances where hazards were recorded, the most frequent was at the 'postanalytical test stage' (n=702, 43.8%), followed closely by 'communication outcomes issues' (n=628, 39.1%).Based on arguably the largest data set currently available on the subject matter, our study findings shed new light on the scale and nature of hazards related to test results handling systems, which can inform future efforts to research and improve the design and reliability of these systems.
Affiliation: Department of Medicine, NHS Education for Scotland, Glasgow, UK Institute of Health and Wellbeing, University of Glasgow, UK.Show MeSH
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Mentions: The developed conceptual model (figure 1) is representative of the test ordering and results handling process as a complex sociotechnical system.10–12 It describes (and potentially predicts) how the hazards at the organisational and cultural levels and across the specific generic stages of the test results system may interact to impact on the well-being of people and on practice performance. The model has the potential to be utilised or adapted by GP teams to prompt reflection and discussion around specific hazards related to different aspects of the results handling system as a means to facilitate risk assessment, potential learning and improvement opportunities as part of the patient safety agenda.
Affiliation: Department of Medicine, NHS Education for Scotland, Glasgow, UK Institute of Health and Wellbeing, University of Glasgow, UK.