2019 Volume 68 Issue 1 Pages 7-12
Recently, the importance of clinical laboratories has increased, and risk management, including incident analyses, is needed for providing reliable laboratory data. We have taken precautions to ensure the prevention of incidents; however, despite such precautions, similar incidents can sometimes occur. The aim of this study is to clarify the characteristics of recurrent incidents; 212 incidents between April 2009 and April 2016 were analyzed. The numbers of nonrecurrent and recurrent incidents were 129 (61%) and 83 (39%), respectively. The most frequent cause of recurrent incidents (68%) was “insufficient recognition”. Precautions for nonrecurrent incidents included changing laboratory practices, such as discontinuing or simplifying procedures. Precautions for recurrent incidents more frequently involved training medical technologists or calling their attention. The modification of circumstances surrounding medical technologists should be considered to prevent recurrent incidents.
