Background

The corona years from 2020 to 2022 led to increased stress for the nursing and physician professions. On one hand, a very high number of sick leaves resulted in a massive workload. On the other hand, there were uncertainties in the private sector such as child day care, elderly care, health safety and job safety of partners. In this study we investigated the impact of the corona pandemic on the frequency of near miss events in hemotherapy.

Methods

At our institution, all near miss events are evaluated semi-annually and reported in the transfusion safety board meetings. This systematic analysis is based on a standardized reporting form to be completed by the person responsible for the mistake. This retrospective study includes all detected near miss events that occurred in the context of hemotherapy from 01/2017 to 04/2023.

Results

Near miss events increased during the years of the corona pandemic (Figure 1). In 2023, 18 events have been reported in the first 4 months, which could resemble a slight decreasing tendency. The most common near miss event was wrong blood in tube correlating with a false identification of the patient while drawing the blood. At our institution, nurses and doctors receive continual training once per year. In addition, a central transfusion medicine training is mandatory for every new clinician. Therefore, a lack of knowledge doesn`t seem to be the main reason for the increasing number of mistakes. In our opinion, lack of accuracy due to overstressing might be the real cause.

Figure 1: near miss events from 2017 to 2023

Conclusion

The corona pandemic had a massive impact on the incidence of near miss events at our institution. For the clinicians it is important to protect the staff for work overload and to strengthen the resilience of nurses and doctors.

Offenlegung Interessenkonflikt:

no conflict of interest