Errors in Laboratory Medicine: Practical Lessons to Improve Patient Safety

2005 ◽  
Vol 129 (10) ◽  
pp. 1252-1261 ◽  
Author(s):  
Peter J. Howanitz
Keyword(s):  
Patient Safety ◽  
Performance Measures ◽  
Improve Patient Safety ◽  
Clinical Pathology ◽  
The United States ◽  
Laboratory Medicine ◽  
Error Reduction ◽  
Error Rates ◽  
Patient Identification ◽  
Improve Patient

Abstract Context.—Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. Objectives.—To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. Setting.—A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Design.—Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. Main Outcome Measures.—A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Results.—Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Conclusions.—Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

Critical Values in Anatomic Pathology

2006 ◽  
Vol 130 (5) ◽  
pp. 638-640 ◽  
Author(s):  
Jan F. Silverman ◽  
Telma C. Pereira
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Clinical Pathology ◽  
Critical Values ◽  
Surgical Pathology ◽  
Anatomic Pathology ◽  
Wide Range ◽  
Enhance Patient Safety ◽  
Pathology Reports ◽  
Improve Patient

Abstract Similar to critical values (CVs) in clinical pathology, occasional diagnoses in surgical pathology and cytology could require immediate notification of the physician to rapidly initiate treatment. However, there are no established CV guidelines in anatomic pathology. A retrospective review of surgical pathology reports was recently conducted to study the incidence of CVs in surgical pathology and to survey the perceptions of pathologists and clinicians about CVs in surgical pathology, with a similar analysis of CVs performed in cytology. The results indicated that CVs in surgical pathology and cytology are uncommon but not rare and that there is a wide range of opinion among pathologists and between pathologists and clinicians about the need for an immediate telephone call and about the degree of urgency. It was obvious from the study that there is a lack of consensus in identifying what constitutes surgical pathology and cytology CV cases. Since the Institute of Medicine's report on medical errors, there has been an increasing number of initiatives to improve patient safety. Having guidelines for anatomic pathology CVs could enhance patient safety, in contrast to the current practice in which CV cases are managed based on common sense and on personal experience. Therefore, a discussion involving the pathology community might prove useful in an attempt to establish anatomic pathology CV guidelines that could represent a practice improvement.

scholarly journals Leveraging IT to Improve Patient Safety

2003 ◽  
Vol 12 (01) ◽  
pp. 153-158
Author(s):  
D.E. Garets ◽  
T.J. Handler ◽  
M.J. Ball
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Quality Care ◽  
Quality Of Healthcare ◽  
The United States ◽  
Institute Of Medicine ◽  
The Media ◽  
The Military ◽  
Improve Patient

Abstract:Medical errors and issues of patient safety are hardly new phenomena. Even during the dawn of medicine, Hippocrates counselled new physicians “to above all else do no harm.” In the United States, efforts to improve the quality of healthcare can be seen in almost every decade of the last century. In the early 1900s, Dr. Ernest Codman failed in his efforts to get fellow surgeons to look at the outcomes of their cases. In the 1970s, there was an outcry that the military allowed an almost blind surgeon to continue to practice and even transferred him to the prestigious Walter Reed Hospital. More recently, two reports by the Institute of Medicine caught the attention of the media, the American public, and the healthcare industry. To Err Is Human highlights the need to reduce medical errors and improve patient safety, and Crossing The Quality Chasm calls for a new health system to provide quality care for the 21st century.

scholarly journals ReCAP: Comparison of Independent Error Checks for Oral Versus Intravenous Chemotherapy

2016 ◽  
Vol 12 (2) ◽  
pp. 168-169 ◽  
Author(s):  
Melissa C. Griffin ◽  
Rachel E. Gilbert ◽  
Larry H. Broadfield ◽  
Anthony E. Easty ◽  
Patricia L. Trbovich ◽  
...  
Keyword(s):  
Patient Safety ◽  
Nova Scotia ◽  
Improve Patient Safety ◽  
Real Life ◽  
Community Pharmacists ◽  
The United States ◽  
Oral Chemotherapy ◽  
Cancer Center ◽  
Community Pharmacies ◽  
Improve Patient

QUESTION ASKED: In the United States, research has found that oral chemotherapy is subject to fewer safeguards than are in routine use for intravenous (IV) chemotherapy; however, less is known about the Canadian context. The objective of this study was to determine whether similar safeguards, in the form of independent checks, existed to identify potential errors related to IV and oral chemotherapy formulations in a particular cancer system. SUMMARY ANSWER: In the cancer system studied, a total of 57 systematic checks were identified for IV chemotherapy, whereas only six systematic checks were identified for oral chemotherapy. Community pharmacists were the only qualified professionals involved in independent, systematic checking of oral chemotherapy, which occurred during ordering and dispensing. METHODS: Human factors specialists conducted observations and interviews in cancer center clinics, a cancer center pharmacy, and four community pharmacies across Nova Scotia. Processes were analyzed to determine whether an independent check was performed, which qualified provider completed the check, and at what point of the process the check occurred. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: This study had some limitations. Although there are many forms of safeguards (eg, preprinted orders), only one type of safeguard (ie, independent checks) was examined in the cancer system studied. We chose to focus on independent checks because they were observable and were defined in the cancer center’s policies. Another limitation was that just a single jurisdiction (Nova Scotia), and four community pharmacies were examined. We examined each community pharmacy in detail, and sites were chosen to be representative (eg, rural versus urban). Further, the model used to deliver oral chemotherapy in Nova Scotia is not unique; a number of other provinces share similar models. REAL-LIFE IMPLICATIONS: There is an enormous opportunity for pharmacists and other qualified professionals to take on an expanded role in improving patient safety for oral chemotherapy. Oral chemotherapy, like IV chemotherapy, is known to be potentially hazardous, but in the cancer system studied, there were dramatically fewer independent checks associated with all aspects of oral chemotherapy–related processes. Greater involvement of pharmacists, both in the clinic environment and the community, would facilitate increased systematic checking, which could improve patient safety related to oral chemotherapy. [Figure: see text]

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.

Feasibility Evaluation of Smart Stretcher to Improve Patient Safety during Transfers

2011 ◽  
Vol 50 (03) ◽  
pp. 253-264 ◽  
Author(s):  
Y. Kurihara ◽  
K. Watanabe ◽  
L. Ohno-Machado ◽  
H. Tanaka ◽  
K. Ohashi
Keyword(s):  
Patient Safety ◽  
Wireless Network ◽  
Medical Staff ◽  
Improve Patient Safety ◽  
Hospital Environment ◽  
Small Scale ◽  
Identification System ◽  
Patient Identification ◽  
Technical Feasibility ◽  
Improve Patient

SummaryObjectives: The integration of noninvasive vital sign sensors and wireless sensor networks into intelligent alarm systems has the potential to improve patient safety. We developed a wireless network-based system (“Smart Stretcher”), which was designed to constantly monitor patient vital signs and detect apnea during transfers within a hospital. The system alerts medical staff in case of an emergency through a wireless network.Methods: A small-scale technical feasibility study was conducted to assess the performance of the system in a simulated hospital environment. Smart Stretcher consists of three components: a small air-mat type pressure sensor measuring respiratory rate and detecting apnea, a patient identification system using RFID technology, and an indoor positioning system using a ZigBee wireless network. In the feasibility experiment, two nurses transferred four subjects who stopped breathing for 10 seconds, after which we calculated the accuracy of apnea detections, repeating this at varying speeds and subject positions. We alsoperformed asubjective evaluation of perceptions and expectations of Smart Stretcher by nurses.Results: The system could detect apnea in all subjects at a rate of over 90%, patient IDs and locations were correctly detected in real time, and the system could alert medical staff. In addition, the results of nurse’s evaluations were mostly positive.Conclusions: The technical feasibility experiment and evaluation of Smart Stretcher suggest that the system could play a key role in monitoring patients during hospital transfers.

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.

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