Author: Leung, Wai-ming
Title: Knowledge management of near misses for clinical laboratory professionals in Hong Kong
Degree: M.Sc.
Year: 2006
Subject: Hong Kong Polytechnic University -- Dissertations.
Medical errors -- Reporting -- China -- Hong Kong.
Knowledge management -- China -- Hong Kong -- Case studies.
Department: Department of Health Technology and Informatics
Pages: 77 leaves : ill. ; 30 cm.
Language: English
Abstract: In the last few years, the issues of patient safety have become important topics in healthcare practice. The current healthcare system focuses on assigning responsibility to individuals and does not encourage open communication among clinical laboratory professionals (CLPs). In order to implement a safety culture, reporting systems need to be confidential and protected from legal discovery (no blame culture), have the necessary resources to investigate events and follow trends, and feed back information to the reporting parties that is perceived to aide their patient safety efforts. These events are then analyzed to uncover the underlying causes of the incidents and to propose corrective actions (learning culture). Near miss reporting becomes a key part of modernization management in quality healthcare - a safety culture. A questionnaire survey was conducted on clinical laboratory professionals' (CLPs) perception on knowledge and attitude on near miss reporting. It also explores the perception of management support for patient safety, management outcomes that would be achieved through enhanced reporting, and correlation between number of near misses reported and recognition of safety culture aspects. Using a self-completed questionnaire developed a postal survey; the questionnaire used in this research included six sections. The survey included one demographic section, one general concept section and 40 items using a 5-point Likert scale and one text item that asked respondents to comment near miss reporting in their organizations. Thirty-six percent of questionnaires were responded (90 out of 250 questionnaires were returned). Analysis revealed specific low-scoring items where improvements can be made, including the perception of blame in errors, no clear policy and template in reporting near misses, more training, education and motivation from leadership required for the benefits of near miss reporting. The survey provides a detailed description of near miss reporting in clinical laboratory professionals (CLPs) in Hong Kong. The findings of this study suggest that CLPs are reluctant to report near misses to their superiors, mainly because of the blame and punishment culture in their organizations. Although laboratory staff agree that near miss reporting is a positive direction for the quality development of healthcare organization, more education and training is required for enhancing the understanding of near misses among CLPs. An alternate means of reporting system rather than adverse events reporting is recommended.
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