“Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory
-
Michael Laposata
Abstract
Data from recent studies suggest that the highest incidence of laboratory-related errors occurs in the pre-analytical phase of laboratory testing. However, few studies have examined the frequency of errors in laboratory test selection and interpretation. A survey of physicians who use our clinical laboratory demonstrated that the largest number of test ordering errors appear to involve physicians simply ordering the wrong test. Diagnostic algorithms providing guidance for test selection in specific disorders are also used as the basis for the establishment of reflex protocols in the clinical laboratory. The provision of an expert-driven interpretation by laboratory professionals resulted in improvements both in the time to and the accuracy of diagnosis. A survey of our physician staff has shown that in the absence of such an interpretation, for patients being assessed for a coagulation disorder, approximately 75% of the cases would have involved some level of test result misinterpretation.
Clin Chem Lab Med 2007;45:712–9.
©2007 by Walter de Gruyter Berlin New York
Articles in the same Issue
- Foreword
- Errors in laboratory medicine and patient safety: the road ahead
- How can we make laboratory testing safer?
- “Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory
- Risk management in the preanalytical phase of laboratory testing
- Recommendations for detection and management of unsuitable samples in clinical laboratories
- Effects of analytic variations in creatinine measurements on the classification of renal disease using estimated glomerular filtration rate (eGFR)
- Process and risk analysis to reduce errors in clinical laboratories
- Reduction of multi-dimensional laboratory data to a two-dimensional plot: a novel technique for the identification of laboratory error
- Does external evaluation of laboratories improve patient safety?
- Risk management in laboratory medicine: quality assurance programs and professional competence
- Point-of-care testing, medical error, and patient safety: a 2007 assessment
- Blood gas and patient safety: considerations based on experience developed in accordance with the Risk Management perspective
- The role of in vitro diagnostic companies in reducing laboratory error
- Application of the Six Sigma concept in clinical laboratories: a review
- One hundred years of laboratory testing and patient safety
Articles in the same Issue
- Foreword
- Errors in laboratory medicine and patient safety: the road ahead
- How can we make laboratory testing safer?
- “Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory
- Risk management in the preanalytical phase of laboratory testing
- Recommendations for detection and management of unsuitable samples in clinical laboratories
- Effects of analytic variations in creatinine measurements on the classification of renal disease using estimated glomerular filtration rate (eGFR)
- Process and risk analysis to reduce errors in clinical laboratories
- Reduction of multi-dimensional laboratory data to a two-dimensional plot: a novel technique for the identification of laboratory error
- Does external evaluation of laboratories improve patient safety?
- Risk management in laboratory medicine: quality assurance programs and professional competence
- Point-of-care testing, medical error, and patient safety: a 2007 assessment
- Blood gas and patient safety: considerations based on experience developed in accordance with the Risk Management perspective
- The role of in vitro diagnostic companies in reducing laboratory error
- Application of the Six Sigma concept in clinical laboratories: a review
- One hundred years of laboratory testing and patient safety
