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

AIM To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. BACKGROUND Surgeons and peri-operative nurses risk acquiring blood-borne viral infections during surgical procedures. Appropriate first-aid and prophylactic treatment after an injury can significantly reduce the risk of infection. However, studies indicate that injuries often go unreported. The 'systems approach' to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety. METHODS A postal survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals, face-to-face interviews with selected participants and telephone interviews with Infection Control Nurses. 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. Only 54.9% (112/204) reported every injury. Surgeons were poorer at reporting: 70/133 (52.6%) reported all or >50% of their injuries compared with 65/71 nurses (91.5%). CONCLUSIONS Injuries are frequently under-reported, possibly compromising safety in operating theatres. IMPLICATIONS FOR NURSING MANAGEMENT A significant number of inoculation injuries are not reported. Factors influencing under-reporting were identified. This knowledge can assist managers in improving reporting and encouraging a robust safety culture within operating departments.