scholarly journals Biochemistry laboratory errors and patient safety: Turkey data

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Hilal Aksoy ◽  
Abdullah Ozturk ◽  
Dilek Tarhan ◽  
Ibrahim Dolukup ◽  
Duygu Ayhan Baser
Keyword(s):  
Patient Safety ◽  
Quality Indicators ◽  
Eastern Anatolia ◽  
University Hospitals ◽  
Ministry Of Health ◽  
Private Hospitals ◽  
Aegean Region ◽  
Laboratory Errors ◽  
Sample Rate

Abstract Objectives Our aim in this study is to provide information about the rate of errors in the process of the biochemistry laboratories in the hospitals in Turkey with the “Indicators”. Methods The hospitals calculate their own data according to the indicator cards defined by the Ministry of Health of Turkey and enter into the system once in a year. In this study we examined the quality indicators related to the disruptions in the biochemistry laboratory of hospitals for the year of 2018. Results All indicators except “Non-timely reported result rate in biochemistry laboratory” are found to be significantly higher in university hospitals. This indicator is found to be significantly higher in private hospitals(p:0.030) “Lost sample rate in biochemistry laboratory” is found to be significantly higher in Eastern Anatolia Region (p:0.000) and “Non-timely reported result rate in biochemistry laboratory” is found to be significantly higher in Aegean Region (p:0.008). Conclusions The ratio of non-timely reported result rate is the most seen disruption in biochemistry laboratories. It may be due to lots of reasons; lack of biochemistry equipment, lack of staff, problems in transportation, etc. The management of hospitals and the staff should take measures and regulations about problems.

scholarly journals Quality Indicators of the Pre-Analytical Phase

2012 ◽  
Vol 31 (3) ◽  
pp. 174-183 ◽  
Author(s):  
Nada Majkić-Singh ◽  
Zorica Šumarac
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Quality Indicators ◽  
Task Force ◽  
Improve Patient Safety ◽  
Laboratory Data ◽  
Sample Collection ◽  
Laboratory Errors ◽  
Analytical Phase ◽  
Total Testing Process

Quality Indicators of the Pre-Analytical PhaseQuality indicatorsare tools that allow the quantification of quality in each of the segments of health care in comparison with selected criteria. They can be defined as an objective measure used to assess the critical health care segments such as, for instance, patient safety, effectiveness, impartiality, timeliness, efficiency, etc. In laboratory medicine it is possible to develop quality indicators or the measure of feasibility for any stage of the total testing process. The total process or cycle of investigation has traditionally been separated into three phases, the pre-analytical, analytical and post-analytical phase. Some authors also include a »pre-pre« and a »post-post« analytical phase, in a manner that allows to separate them from the activities of sample collection and transportation (pre-analytical phase) and reporting (post-analytical phase). In the year 2008 the IFCC formed within its Education and Management Division (EMD) a task force calledLaboratory Errors and Patient Safety (WG-LEPS)with the aim of promoting the investigation of errors in laboratory data, collecting data and developing a strategy to improve patient safety. This task force came up with the Model of Quality Indicators (MQI) for the total testing process (TTP) including the pre-, intra- and post-analytical phases of work. The pre-analytical phase includes a set of procedures that are difficult to define because they take place at different locations and at different times. Errors that occur at this stage often become obvious later in the analytical and post-analytical phases. For these reasons the identification of quality indicators is necessary in order to avoid potential errors in all the steps of the pre-analytical phase.

Pre-analytical quality indicators in laboratory medicine: Performance of laboratories participating in the IFCC working group “Laboratory Errors and Patient Safety” project

2019 ◽  
Vol 497 ◽  
pp. 35-40 ◽  
Author(s):  
Laura Sciacovelli ◽  
Giuseppe Lippi ◽  
Zorica Sumarac ◽  
Isabel Garcia del Pino Castro ◽  
Agnes Ivanov ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Indicators ◽  
Working Group ◽  
Laboratory Medicine ◽  
Analytical Quality ◽  
Laboratory Errors

scholarly journals Preanalytical errors in medical laboratories: a review of the available methodologies of data collection and analysis

2016 ◽  
Vol 54 (1) ◽  
pp. 14-19 ◽  
Author(s):  
Jamie West ◽  
Jennifer Atherton ◽  
Seán J Costelloe ◽  
Ghazaleh Pourmahram ◽  
Adam Stretton ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Management ◽  
Data Collection ◽  
Quality Indicators ◽  
Management Systems ◽  
Continual Improvement ◽  
Laboratory Errors ◽  
Data Collection Methods ◽  
The Impact ◽  
Collection Methods

Preanalytical errors have previously been shown to contribute a significant proportion of errors in laboratory processes and contribute to a number of patient safety risks. Accreditation against ISO 15189:2012 requires that laboratory Quality Management Systems consider the impact of preanalytical processes in areas such as the identification and control of non-conformances, continual improvement, internal audit and quality indicators. Previous studies have shown that there is a wide variation in the definition, repertoire and collection methods for preanalytical quality indicators. The International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient Safety has defined a number of quality indicators for the preanalytical stage, and the adoption of harmonized definitions will support interlaboratory comparisons and continual improvement. There are a variety of data collection methods, including audit, manual recording processes, incident reporting mechanisms and laboratory information systems. Quality management processes such as benchmarking, statistical process control, Pareto analysis and failure mode and effect analysis can be used to review data and should be incorporated into clinical governance mechanisms. In this paper, The Association for Clinical Biochemistry and Laboratory Medicine PreAnalytical Specialist Interest Group review the various data collection methods available. Our recommendation is the use of the laboratory information management systems as a recording mechanism for preanalytical errors as this provides the easiest and most standardized mechanism of data capture.

Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators

Diagnosis ◽  
2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Wilson Shcolnik ◽  
Fernando Berlitz ◽  
Cesar Alex de O. Galoro ◽  
Vinicius Biasoli ◽  
Rafael Lopes ◽  
...  
Keyword(s):  
Patient Safety ◽  
Best Practices ◽  
Quality Indicators ◽  
Monitoring Program ◽  
Laboratory Medicine ◽  
Comparative Performance ◽  
Pathology Laboratory ◽  
Pareto Chart ◽  
Laboratory Errors ◽  
Analytical Phase

AbstractObjectivesIn the laboratory medicine segment, benchmarking is the process in which institutions seek to compare with the macro environment (performance comparison and best practices with different laboratories) and improve their results based on quality indicators. The literature has highlighted the vulnerability of the pre-analytical phase in terms of risks and failures and the use of interlaboratory comparison as an opportunity to define a strategic performance benchmark aligned with the laboratory medicine sector, which has been a promising strategy to ensure continuous improvement, identifying within the pre-analytical process the critical activities to guarantee patient safety. In this context, this paper aims to present the three-year experience (2016–2018) of the Benchmarking Program and Laboratory Indicators – in Portuguese, Programa de Benchmarking e Indicadores Laboratoriais (PBIL) – with emphasis on pre-analytical indicators and their comparison against literature references and other programs of benchmarking in the area of laboratory medicine. PBIL is organized by the Brazilian Society of Clinical Pathology/Laboratory Medicine (SBPC/ML) in conjunction with Controllab and coordinated by a Brazilian group with representatives from different countries.MethodsThe data presented in this paper involving the performance results of 180 laboratories with active participation. Results are presented in percentage (%, boxplot graphical in quartiles) and Sigma metric, recognized as the metric that best indicates the magnitude of failures in a process. The Pareto Chart was used to facilitate ordering and to identify the main errors in the pre-analytical phase. The Radar Chart was made available in this work for the purpose of comparing the results obtained in Sigma by the PBIL and IFCC Working Group Laboratory Errors and Patient Safety (WG LEPS).ResultsIn the study period, just over 80% of the pre-analytical failures are related to Blood culture contamination (hospital-based and non-hospital-based laboratories), Recollect and Non-registered exams, with failure rates of 2.70, 1.05 and 0.63%, respectively. The performance of the PBIL program participants was in line with the literature references, and allowed to identify benchmarks in the laboratory medicine market, target of PBIL, with best practices were observed for some indicators.ConclusionsThe results of the program demonstrate the importance of an ongoing program comparative performance-monitoring program for setting more robust goals and consequently reducing laboratory process failures. Even with these promising premises and results, the contextualized analysis of the program indicators, point to a still significant number of failures in our market, with possibilities for improvement in order aiming to ensure more robust and effective processes.

scholarly journals Quality Indicators in Laboratory Medicine: the status of the progress of IFCC Working Group “Laboratory Errors and Patient Safety” project

2017 ◽  
Vol 55 (3) ◽  
Author(s):  
Laura Sciacovelli ◽  
Giuseppe Lippi ◽  
Zorica Sumarac ◽  
Jamie West ◽  
Isabel Garcia del Pino Castro ◽  
...  
Keyword(s):  
Patient Safety ◽  
Data Collection ◽  
Quality Indicators ◽  
Working Group ◽  
State Of The Art ◽  
Laboratory Medicine ◽  
Error Rates ◽  
International Standard ◽  
Laboratory Errors ◽  
The Individual

AbstractThe knowledge of error rates is essential in all clinical laboratories as it enables them to accurately identify their risk level, and compare it with those of other laboratories in order to evaluate their performance in relation to the State-of-the-Art (i.e. benchmarking) and define priorities for improvement actions. Although no activity is risk free, it is widely accepted that the risk of error is minimized by the use of Quality Indicators (QIs) managed as a part of laboratory improvement strategy and proven to be suitable monitoring and improvement tools. The purpose of QIs is to keep the error risk at a level that minimizes the likelihood of patients. However, identifying a suitable State-of-the-Art is challenging, because it calls for the knowledge of error rates measured in a variety of laboratories throughout world that differ in their organization and management, context, and the population they serve. Moreover, it also depends on the choice of the events to keep under control and the individual procedure for measurement. Although many laboratory professionals believe that the systemic use of QIs in Laboratory Medicine may be effective in decreasing errors occurring throughout the total testing process (TTP), to improve patient safety as well as to satisfy the requirements of International Standard ISO 15189, they find it difficult to maintain standardized and systematic data collection, and to promote continued high level of interest, commitment and dedication in the entire staff. Although many laboratories worldwide express a willingness to participate to the Model of QIs (MQI) project of IFCC Working Group “Laboratory Errors and Patient Safety”, few systematically enter/record their own results and/or use a number of QIs designed to cover all phases of the TTP. Many laboratories justify their inadequate participation in data collection of QIs by claiming that the number of QIs included in the MQI is excessive. However, an analysis of results suggests that QIs need to be split into further measurements. As the International Standard on Laboratory Accreditation and approved guidelines do not specify the appropriate number of QIs to be used in the laboratory, and the MQI project does not compel laboratories to use all the QIs proposed, it appears appropriate to include in the MQI all the indicators of apparent utility in monitoring critical activities. The individual laboratory should also be able to decide how many and which QIs can be adopted. In conclusion, the MQI project is proving to be an important tool that, besides providing the TTP error rate and spreading the importance of the use of QIs in enhancing patient safety, highlights critical aspects compromising the widespread and appropriate use of QIs.

A pilot study for establishing quality indicators in molecular diagnostics according to the IFCC WG-LEPS initiative: preliminary findings in China

2019 ◽  
Vol 57 (6) ◽  
pp. 822-831 ◽  
Author(s):  
Rui Zhou ◽  
Yali Wei ◽  
Laura Sciacovelli ◽  
Mario Plebani ◽  
Qingtao Wang
Keyword(s):  
Patient Safety ◽  
Quality Indicators ◽  
Molecular Diagnostics ◽  
Clinical Chemistry ◽  
Priority Level ◽  
Laboratory Errors ◽  
Promising Tool ◽  
Laboratory Services ◽  
Total Testing Process

Abstract Background Quality indicators (QIs) are crucial tools in measuring the quality of laboratory services. Based on the general QIs of the Working Group “Laboratory Errors and Patient Safety (WG-LEPS)” of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), specific QIs have been established in order to monitor and improve the quality of molecular diagnostics, and to assess the detection level of associated disease. Methods A survey was conducted on 46 independent commercial laboratories in China, investigated using questionnaires and on-site inspections. Specific QIs established were mainly based on the specific laboratory work-flow for molecular diagnoses. The specific QI results from three volunteer laboratories were collected and used to validate their effectiveness. Results Of the 46 laboratories participating in the study, 44 (95.7%), conducted molecular diagnostics. Of 13 specific established QIs, six were priority level 1, and seven, priority level 3. At pre-evaluation of data from the three volunteering laboratories, it was found that the newly classified specific QIs had outstanding advantages in error identification and risk reduction. Conclusions Novel specific QIs, a promising tool for monitoring and improving upon the total testing process in molecular diagnostics, can effectively contribute to ensuring patient safety.

scholarly journals Evaluation of pre-analytical phase performance of emergency laboratory by harmonized quality indicators and six sigma

2021 ◽  
Vol 9 (2) ◽  
pp. 64-70
Author(s):  
Arumalla VK ◽  
Chelliah S ◽  
Madhubala V
Keyword(s):  
Patient Safety ◽  
Quality Indicators ◽  
Six Sigma ◽  
Working Group ◽  
Clinical Chemistry ◽  
International Federation ◽  
Laboratory Errors ◽  
The World ◽  
Analytical Phase ◽  
Analytical Errors

Background: Pre-analytical errors account for up to 70% of all the errors made in laboratory diagnostics which are mostly not directly under laboratory control. Laboratories across the world have been using different Quality indicators (QIs) for identifying and quantification of pre-analytical errors. Objective of the present study is to identify the different pre-analytical errors with their frequency and to assess the pre-analytical phase performance of emergency laboratory by using harmonized Quality Indicators and six sigma metrics. Methods and material: A prospective observational study was conducted from January 2019 to December 2019 to monitor the inappropriateness of samples and test request forms. We have quantified the performance of pre-analytical phase of our emergency laboratory based on the harmonized QIs proposed by The International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient Safety (IFCC- WGLEPS) and six sigma metrics. Results: Emergency laboratory received a total of 55431 samples during Jan- 2019 to Dec- 2019. Number of pre-analytical errors were 1089 which accounted for 1.96% of total samples received. Haemolysed samples, clotted samples and samples with insufficient volume were contributed to 37%, 26% and 15% of the total pre-analytical errors respectively. Conclusions: Pre-analytical phase performance of our emergency laboratory complies with the quality specifications laid by the International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient Safety (IFCC-WGLEPS). Implementation of harmonised QIs assures the comparability of laboratory findings with different laboratories across the world.

scholarly journals Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: a consensus statement on behalf of the IFCC Working Group “Laboratory Error and Patient Safety” and EFLM Task and Finish Group “Performance specifications for the extra-analytical phases”

2017 ◽  
Vol 55 (10) ◽  
Author(s):  
Laura Sciacovelli ◽  
Mauro Panteghini ◽  
Giuseppe Lippi ◽  
Zorica Sumarac ◽  
Janne Cadamuro ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Indicators ◽  
Working Group ◽  
Group Performance ◽  
Clinical Chemistry ◽  
Deep Understanding ◽  
Laboratory Medicine ◽  
Laboratory Errors ◽  
Finish Group ◽  
Performance Specifications

AbstractThe improving quality of laboratory testing requires a deep understanding of the many vulnerable steps involved in the total examination process (TEP), along with the identification of a hierarchy of risks and challenges that need to be addressed. From this perspective, the Working Group “Laboratory Errors and Patient Safety” (WG-LEPS) of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is focusing its activity on implementation of an efficient tool for obtaining meaningful information on the risk of errors developing throughout the TEP, and for establishing reliable information about error frequencies and their distribution. More recently, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has created the Task and Finish Group “Performance specifications for the extra-analytical phases” (TFG-PSEP) for defining performance specifications for extra-analytical phases. Both the IFCC and EFLM groups are working to provide laboratories with a system to evaluate their performances and recognize the critical aspects where improvement actions are needed. A Consensus Conference was organized in Padova, Italy, in 2016 in order to bring together all the experts and interested parties to achieve a consensus for effective harmonization of quality indicators (QIs). A general agreement was achieved and the main outcomes have been the release of a new version of model of quality indicators (MQI), the approval of a criterion for establishing performance specifications and the definition of the type of information that should be provided within the report to the clinical laboratories participating to the QIs project.

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

2021 ◽  
pp. 108482232110021
Author(s):  
Alireza Nikbakht Nasrabadi ◽  
Leila Mardanian Dehkordi ◽  
Fariba Taleghani
Keyword(s):  
Patient Safety ◽  
Data Collection ◽  
Continuity Of Care ◽  
Chronic Conditions ◽  
Transitional Care ◽  
Major Elements ◽  
Study Data ◽  
Multiple Chronic Conditions ◽  
University Hospitals ◽  
Levels Of Care

Transitional care is a designed plan to ensure the continuity of care received by patients as they transfer between different locations or levels of care. The aim of this paper is to explore nurses’ experiences of transitional care in multiple chronic conditions. A qualitative method with a conventional content analysis approach was utilized. The study was conducted at university hospitals in 2 big cities (Isfahan and Tehran) of Iran. This study is performed from November 2018 to December 2019 using deep, semi-structured, and face-to-face interviews which are focused on nurses’ experiences of transitional care. Data collection continued until saturation was reached. Finally, 15 nurses take part in this study. Data collection and data analysis were conducted concurrently. Data were analyzed using Graneheim and Lundman’s techniques. Two main themes providing a descriptive summary of the major elements of transitional care identified: “threat to patient safety” and “Care breakdown”. Findings showed an exclusive image of unsafe transitional care which was done unplanned without appropriate delegating care to family and threat patient safety. There is still a gap in the transition from hospital to home. Nursing managers can address this issue by creating a culture of teamwork, training competent nurses by continuum education, and more supervision of nursing care. Policymakers can ensure continuity of care by developing policies and programs about transitional care.

Top four types of sentinel events in Saudi Arabia during the period 2016–19

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Nasser Altalhi ◽  
Haifa Alnaimi ◽  
Mafaten Chaouali ◽  
Falaa Alahmari ◽  
Noor Alabdulkareem ◽  
...  
Keyword(s):  
Health Care ◽  
Saudi Arabia ◽  
Patient Safety ◽  
Reporting System ◽  
Improve Patient Safety ◽  
Health Care Facilities ◽  
Common Root ◽  
Private Hospitals ◽  
Care Facilities ◽  
Sentinel Events

Abstract Background This study discusses the summary, investigation and root causes of the top four sentinel events (SEs) in Saudi Arabia (SA) that occurred between January 2016 and December 2019, as reported by the Ministry of Health (MOH) and private hospitals through the MOH SE reporting system (SERS). It is intended for use by legislators, health-care facilities and the public to shed light on areas that still need improvement to preserve patient safety. Objectives The purpose of this study is to review the most common SEs reported by the MOH and private hospitals between the years 2016 and 2019 to assess the patterns and identify risk areas and the common root causes of these events in order to promote country-wide learning and support services that can improve patient safety. Methods In this retrospective descriptive study, the data were retrieved from the SERS, which routinely collects records from both MOH and private hospitals in SA. SEs were analyzed by type of event, location, time, patient demographics, outcome and root causes. Results There were 727 SEs during this period, 38.4% of which were under the category of unexpected patient death, 19.4% under maternal death, 11.7% under unexpected loss of limb or function and 9.9% under retained instruments or sponge. Common root causes were related to policies and procedures, guidelines, miscommunication between health-care facilities, shortage of staff and lack of competencies. Conclusion Given these results, efforts should focus on improving the care of deteriorating patients in general wards, ICU (Intensive Care Units) admission/discharge criteria and maternal, child and surgical safety. The results also highlighted the problem of underreporting of SEs, which needs to be addressed and improved. Linking data sources such as claims and patient complaints databases and electronic medical records to the national reporting system must also be considered to ensure an optimal estimation of the number of events.

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