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The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

Jayne Cutter, Sue Jordan Orcid Logo

Journal of Nursing Management, Volume: 21, Issue: 8, Pages: 989 - 1000

Swansea University Authors: Jayne Cutter, Sue Jordan Orcid Logo

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Abstract

Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background: the risk of acquiring a blood-borne viral infection during exposure prone procedures has been estimated as 0.3% for HIV, 3% for hepatitis C virus and appr...

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Published in: Journal of Nursing Management
ISSN: 09660429
Published: Blackwell Publishing 2013
Online Access: Check full text

URI: https://cronfa.swan.ac.uk/Record/cronfa10810
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Abstract: Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background: the risk of acquiring a blood-borne viral infection during exposure prone procedures has been estimated as 0.3% for HIV, 3% for hepatitis C virus and approximately 30% for hepatitis B virus (HBV) among non-vaccinated personnel Appropriate floow up including first-aid and prophylactic treatment after an injury can reduce the risk of infection. However, injuries are often under-reported. The systems approach to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety.Method A multi-site, cross sectional survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals (n=315), semi-structured interviews with selected participants (n=16) and telephone interviews with Infection Control Nurses (n=6).Results The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. However, reporting was inconsistent with only 54.9% of respondents (112/204) reporting all injuries. 70/133 of surgeons (52.6%) vs 65/71 nurses (91.5%)reported all or >50% of their injuries.Conclusions Injuries are frequently under-reported, possibly compromising safety in operating theatres. Understanding the factors that influence under-reporting can underpin measures to improve reporting and ultimately improve safety.
Item Description: Published on line 16/06/12
Keywords: Error reduction, injury reporting, peri-operative nurses, surgeons,
College: College of Human and Health Sciences
Issue: 8
Start Page: 989
End Page: 1000