scholarly journals Medical Errors: Pre-Analytical Issue in Patient Safety

2010 ◽  
Vol 29 (4) ◽  
pp. 310-314 ◽  
Author(s):  
Mario Plebani ◽  
Elisa Piva
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Health Care Services ◽  
Negative Impact ◽  
Blood Collection ◽  
Patient Identification ◽  
Important Lesson ◽  
Laboratory Errors ◽  
Analytical Issue ◽  
Total Testing Process

Medical Errors: Pre-Analytical Issue in Patient SafetyThe last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories, while a growing body of evidence demonstrates that the pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. In particular, most errors are identified in pre-pre-analytic steps outside the walls of the laboratory, and beyond its control. However, in a patient-centred approach to the delivery of health care services, there is the need to investigate, in the total testing process, any possible defect that may have a negative impact on the patient, irrespective of which step is involved and whether the error depends on a laboratory professional (e.g. calibration or testing error) or a non-laboratory operator (e.g. inappropriate test request, error in patient identification and/or blood collection). In the pre-analytic phase, the frequency of patient/specimens misidentification and the presence of possible causes of specimen rejection (haemolysis, clotting, insufficient volume, etc.) represent a valuable risk for patient safety. Preventing errors in the pre-analytical steps requires both technological developments (wristband, barcodes, pre-analytical workstations) and closer relationships with the clinical world to achieve an effective team-working cooperation. The most important lesson we have learned, therefore, is that laboratory errors and injuries to patients can be prevented by redesigning systems that render it difficult for all caregivers and in all steps of the total testing process to make mistakes.

scholarly journals Blood sampling guidelines with focus on patient safety and identification – a review

Diagnosis ◽  
2018 ◽  
Vol 0 (0) ◽  
Author(s):  
Michael Cornes ◽  
Mercedes Ibarz ◽  
Helene Ivanov ◽  
Kjell Grankvist
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Venous Blood ◽  
Blood Collection ◽  
Patient Identification ◽  
Open Questions ◽  
Working Groups ◽  
Analytical Phase ◽  
Total Testing Process ◽  
Improve Patient

AbstractIt has been well documented over recent years that the pre-analytical phase is a leading contributor to errors in the total testing process (TTP). There has however been great progress made in recent years due to the exponential growth of working groups specialising in the field. Patient safety is clearly at the forefront of any healthcare system and any reduction in errors at any stage will improve patient safety. Venous blood collection is a key step in the TTP, and here we review the key errors that occur in venous phlebotomy process and summarise the evidence around their significance to patient safety. Recent studies have identified that patient identification and tube labelling are the steps that carry the highest risk with regard to patient safety. Other studies have shown that in 16.1% of cases, patient identification is incorrectly performed and that 56% of patient identification errors are due to poor labelling practice. We recommend that patient identification must be done using open questions and ideally three separate pieces of information. Labelling of the tube or linking the identity of the patient to the tube label electronically must be done in the presence of the patient whether it is before or after sampling. Combined this will minimise any chance of patient misidentification.

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.

Laboratory-associated and diagnostic errors: a neglected link

Diagnosis ◽  
2014 ◽  
Vol 1 (1) ◽  
pp. 89-94 ◽  
Author(s):  
Mario Plebani
Keyword(s):  
Patient Safety ◽  
Laboratory Testing ◽  
Improve Patient Safety ◽  
Total Error ◽  
Diagnostic Errors ◽  
Error Rates ◽  
Blood Collection ◽  
Care Providers ◽  
Patient Identification ◽  
Test Request

AbstractClinical laboratories play a vital role in patient care, but many diagnostic errors are associated with laboratory testing. The past decades have seen sustained improvements in analytical performances but the error rates, particularly in pre- and post-analytical phases is still high. Although the seminal concept of the brain-to-brain laboratory loop has been described more than four decades ago, the awareness about the importance of extra-analytical aspects in laboratory quality is a recent achievement. According to this concept, all phases and activities of the testing cycle should be assessed, monitored and improved in order to decrease the total error rates and thereby improve patient safety. In the interests of patients, any direct or indirect negative consequence related to a laboratory test must be considered, irrespective of which step is involved and whether the error depends on a laboratory professional (e.g., calibration or testing error) or a non-laboratory operator (e.g., inappropriate test request, error in patient identification and/or blood collection). Data collected in various clinical settings demonstrate that many diagnostic errors are associated with laboratory testing. In particular, errors are due to inappropriate test request and/or result interpretation and utilization. Collaborations between laboratory professionals and other care providers, namely clinicians and nurses, are needed to achieve the goal of improved patient safety.

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.

Patient Safety in the Clinical Laboratory: A Longitudinal Analysis of Specimen Identification Errors

2006 ◽  
Vol 130 (11) ◽  
pp. 1662-1668 ◽  
Author(s):  
Elizabeth A. Wagar ◽  
Lorraine Tamashiro ◽  
Bushra Yasin ◽  
Lee Hilborne ◽  
David A. Bruckner
Keyword(s):  
Patient Safety ◽  
Trend Analysis ◽  
Clinical Laboratory ◽  
Processing System ◽  
Health Care Team ◽  
Interdisciplinary Teams ◽  
T Test ◽  
Patient Identification ◽  
Outcomes Of Care ◽  
Total Testing Process

Abstract Context.—Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. Objective.—To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Design.—Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Results.—Of 16 632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Conclusions.—Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

Penanganan Issu Terkait Keselamatan Pasien di Rumah Sakit

2020 ◽  
Author(s):  
Kristin Natal Riang Gea
Keyword(s):  
Patient Safety ◽  
Health Workers ◽  
Sampling Technique ◽  
Good Health ◽  
Bivariate Analysis ◽  
P Value ◽  
Patient Identification ◽  
Cross Sectional ◽  
The Right ◽  
The Relationship

AbstrakKeselamatan pasien merupakan dasar dari pelayanan kesehatan yang baik. Pengetahuan tenaga kesehatan dalam sasaran keselamatan pasien terdiri dari ketepatan identifikasi pasien, peningkatan komunikasi yang efektif, peningkatan keamanan obat yang perlu diwaspadai, kepastian tepat lokasi, prosedur, dan tepat pasien operasi, pengurangan risiko infeksi, pengurangan risiko pasien jatuh. Tujuan penelitian untuk mengetahui hubungan antara pengetahuan dengan penerapan keselamatan pasien pada petugas kesehatan di Puskesmas Kedaung Wetan Kota Tangerang. Metode Penelitian menggunakan deskriptif korelasi menggunakan pendekatan cross sectional. Populasi sebanyak 50 responden. Teknik pengambilan sampel menggunakan total sampling. Instrumen yang digunakan berupa lembar kuesioner. Teknik analisa diatas menggunakan analisa Univariat dan Bivariat. Hasil Penelitian ada Hubungan Pengetahuan dengan Penerapan Keselamatan Pasien pada Petugas Kesehatan, dengan hasil, p value sebesar 0,013 < 0,05 maka dapat disimpulkan bahwa ada Hubungan Pengetahuan dengan Penerapa Keselamatan Pasien pada Petugas Kesehatan. Kesimpulan penelitian ada Hubungan Pengetahuan dengan Penerapan Keselamatan Pasien.. AbstrackPatient safety is the basis of good health services. Knowledge of health personnel in patient safety targets consists of accurate patient identification, increased effective communication, increased safety of the drug that needs to be watched, certainty in the right location, procedure, and precise patient surgery, reduction in risk of infection, reduction in risk of falling patients. The purpose of this study was to determine the relationship between knowledge and the application of patient safety to health workers in the Kedaung Wetan Health Center, Tangerang City. The research method uses descriptive correlation using cross sectional approach. The population is 50 respondents. The sampling technique uses total sampling. The instrument used was a questionnaire sheet. The analysis technique above uses Univariate and Bivariate analysis. The results of the study there is a Relationship of Knowledge with the Implementation of Patient Safety in Health Officers, with the result, p value of 0.013 <0.05, it can be concluded that there is a Relationship between Knowledge and Patient Safety Implementation in Health Officers. The conclusion of the study is the Relationship between Knowledge and the Implementation of Patient Safety.Keywords Knowledge, Patient safety, Health workers

Assessment of laboratory errors and best laboratory practices

2016 ◽  
Vol 5 (07) ◽  
pp. 4704
Author(s):  
Syed Riaz Mehdi* ◽  
Sharique Ahmad ◽  
Noorin Zaidi
Keyword(s):  
External Quality Control ◽  
External Quality ◽  
Iso 15189 ◽  
Laboratory Errors ◽  
Control Programs ◽  
Medical Laboratories ◽  
Laboratory Error ◽  
Active Communication ◽  
Total Testing Process ◽  
Five Phases

Laboratory error is defined by ISO 22367 as “Failure of planned actions to be completed as intended or use a wrong plan to achieve an aim”. Lundeberg in 1981 outlined the concept of Total Testing Process (TTP) and Plebani elaborated it further and classified the whole testing process into five phases of Pre-Pre Analytic, Pre Analytic, Analytic, Post Analytic and Post - Post Analytic. The errors have to be identified and resolved in each phase of the process. The medical laboratories have to run Internal and External Quality Control programs and abide by the guidelines of ISO 15189 in order to be accredited by bodies like JCI, CAP or NABL. Active communication and regular interaction between the clinicians and the laboratory is recommended during Pre Analytic and Post Analytic phases of TTP in order to achieve the target of Best Laboratory Practices. 

scholarly journals The Concept of Surgical Assessment: Part 3 – Characteristics of the Ideal Assessment Tool

2010 ◽  
Vol 92 (9) ◽  
pp. 1-2 ◽  
Author(s):  
T Okoro ◽  
C Sirianni ◽  
D Brigden
Keyword(s):  
Patient Safety ◽  
Skill Acquisition ◽  
Medical Errors ◽  
Assessment Tool ◽  
Training Programme ◽  
Technical Competence ◽  
Operating Room Efficiency ◽  
European Working ◽  
Teaching Faculty ◽  
The Ideal

Adequate documentation of technical competence in surgery has come under increased scrutiny in recent years. The stipulation in the European Working Time Regulations of a 48-hour working week, an emphasis on operating room efficiency and concerns about medical errors and patient safety may limit the ability of a teaching faculty to provide graded responsibility with adequate skill acquisition in a surgical training programme.

scholarly journals The Impact of a Location-Sensing Electronic Health Record on Clinician Efficiency and Accuracy: A Pilot Simulation Study

2018 ◽  
Vol 09 (04) ◽  
pp. 841-848
Author(s):  
Kevin King ◽  
John Quarles ◽  
Vaishnavi Ravi ◽  
Tanvir Chowdhury ◽  
Donia Friday ◽  
...  
Keyword(s):  
Patient Safety ◽  
Pilot Study ◽  
Human Computer Interaction ◽  
Real Time ◽  
Identification Accuracy ◽  
Patient Identification ◽  
Location Services ◽  
Electronic Health ◽  
The Impact ◽  
Computer Interaction

Background Through the Health Information Technology for Economic and Clinical Health Act of 2009, the federal government invested $26 billion in electronic health records (EHRs) to improve physician performance and patient safety; however, these systems have not met expectations. One of the cited issues with EHRs is the human–computer interaction, as exhibited by the excessive number of interactions with the interface, which reduces clinician efficiency. In contrast, real-time location systems (RTLS)—technologies that can track the location of people and objects—have been shown to increase clinician efficiency. RTLS can improve patient flow in part through the optimization of patient verification activities. However, the data collected by RTLS have not been effectively applied to optimize interaction with EHR systems. Objectives We conducted a pilot study with the intention of improving the human–computer interaction of EHR systems by incorporating a RTLS. The aim of this study is to determine the impact of RTLS on process metrics (i.e., provider time, number of rooms searched to find a patient, and the number of interactions with the computer interface), and the outcome metric of patient identification accuracy Methods A pilot study was conducted in a simulated emergency department using a locally developed camera-based RTLS-equipped EHR that detected the proximity of subjects to simulated patients and displayed patient information when subjects entered the exam rooms. Ten volunteers participated in 10 patient encounters with the RTLS activated (RTLS-A) and then deactivated (RTLS-D). Each volunteer was monitored and actions recorded by trained observers. We sought a 50% improvement in time to locate patients, number of rooms searched to locate patients, and the number of mouse clicks necessary to perform those tasks. Results The time required to locate patients (RTLS-A = 11.9 ± 2.0 seconds vs. RTLS-D = 36.0 ± 5.7 seconds, p < 0.001), rooms searched to find patient (RTLS-A = 1.0 ± 1.06 vs. RTLS-D = 3.8 ± 0.5, p < 0.001), and number of clicks to access patient data (RTLS-A = 1.0 ± 0.06 vs. RTLS-D = 4.1 ± 0.13, p < 0.001) were significantly reduced with RTLS-A relative to RTLS-D. There was no significant difference between RTLS-A and RTLS-D for patient identification accuracy. Conclusion This pilot demonstrated in simulation that an EHR equipped with real-time location services improved performance in locating patients and reduced error compared with an EHR without RTLS. Furthermore, RTLS decreased the number of mouse clicks required to access information. This study suggests EHRs equipped with real-time location services that automates patient location and other repetitive tasks may improve physician efficiency, and ultimately, patient safety.

scholarly journals Ações educativas para identificação correta do paciente: relato de experiência

2021 ◽  
Vol 11 (34) ◽  
pp. 152-159
Author(s):  
Gabriele Malta da Costa ◽  
Paloma Vitória Serra Batista ◽  
Luana Ferreira de Almeida ◽  
Ronilson Gonçalves Rocha ◽  
Bruna Maiara Ferreira Barreto Pires ◽  
...  
Keyword(s):  
Patient Safety ◽  
Nursing Students ◽  
Health Professionals ◽  
Rio De Janeiro ◽  
Inservice Training ◽  
University Hospital ◽  
Correct Identification ◽  
Patient Identification ◽  
Interactive Training ◽  
Inpatient Units

Relatar a experiência vivenciada por discentes e docentes de enfermagem na realização de atividades extensionistas para o aumento da adesão à identificação correta do paciente. Relato de experiencia acerca da importância da identificação correta do paciente realizadas em um hospital universitário do Estado do Rio de Janeiro de setembro de 2019 a março de 2020. Participaram profissionais de saúde, pacientes e acompanhantes. Para profissionais de saúde, foram desenvolvidos treinamentos interativos. Para pacientes e acompanhantes, elencou-se orientações acerca da importância da identificação do paciente. Realizados dezoito treinamentos, a maioria com técnicos de enfermagem (54 - 37,76%) e enfermeiros (23 - 16,08%). Alcançadas 2.050 orientações, sendo com 998 (48,68%) pacientes. As atividades ocorreram em 32 unidades de internação. Pode-se contribuir com atividades da Meta 1 de Segurança do Paciente, além de destacar a importância de Projetos de Extensão Universitária para melhor assistência. Descritores: Segurança do Paciente, Sistemas de Identificação de Pacientes, Capacitação em Serviço, Hospitais Universitários. Educational actions for correct patient identification: experience reportAbstract: To report the experience lived by nursing students and teachers in carrying out extension activities to increase adherence to the correct identification of the patient. Experience report about the importance of correct patient identification performed at an university hospital in the State of Rio de Janeiro from September 2019 to March 2020. The group of participants was health professionals, patients and companions. For health professionals, was developed interactive training. For patients and companions, guidelines were listed on the importance of patient identification. Eighteen training sessions were carried out, most with nursing technicians (54 - 37.76%) and nurses (23 - 16.08%). 2,050 guidelines were reached, with 998 (48.68%) patients. The activities took place in 32 inpatient units. It is possible to contribute to the activities of Patient Safety of Goal 1, in addition to highlighting the importance of University Extension Projects for better assistance.Descriptors: Patient Safety, Patient Identification Systems, Inservice Training, Hospital University. Acciones educativas para la identificación correcta del paciente: informe de experienciaResumen: Relatar la experiencia vivida por estudiantes y docentes de enfermería en la realización de actividades de extensión para incrementar la adherencia a la correcta identificación del paciente. Relato de experiencia sobre la importancia de la correcta identificación del paciente realizado en un hospital universitario del Estado de Rio de Janeiro de septiembre de 2019 a marzo de 2020. Participaron profesionales de la salud, pacientes y acompañantes. Para los profesionales de la salud, se desarrolló una formación interactiva. Para pacientes y acompañantes, se enumeraron pautas sobre la importancia de la identificación del paciente. Se realizaron 18 capacitaciones, la mayoría con técnicos de enfermería (54 - 37,76%) y enfermeras (23 - 16,08%). Se alcanzaron 2.050 guías, con 998 (48,68%) pacientes. Las actividades se desarrollaron en 32 unidades de internación. Es posible contribuir a las actividades de la Meta 1 de Seguridad del Paciente, además de resaltar la importancia de los Proyectos de Extensión Universitaria para una mejor atención.Descriptores: Seguridad del Paciente, Sistemas de Identificación de Pacientes, Capacitación em Servicio, Hospitais Universitarios.

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