Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system

Veronica Restelli; Annemarie Taylor; Douglas Cochrane; Michael A. Noble

doi:10.1515/dx-2017-0013

Article

Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system

Veronica Restelli , Annemarie Taylor , Douglas Cochrane and Michael A. Noble

Published/Copyright: May 23, 2017

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From the journal Diagnosis Volume 4 Issue 2

Abstract

Background:

This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System.

Methods:

The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported.

Results:

Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences.

Conclusions:

It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.

Keywords: laboratory error; patient safety; post-analytical; pre-analytical; quality; reporting system

Corresponding author: Michael A. Noble, MD, FRCPC, University of British Columbia, Program Office for Laboratory Quality Management, Room G409 – 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5, Phone: +1-604-827-1337

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

References

1. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med 2009;47:143–53.10.1515/CCLM.2009.045Search in Google Scholar

2. O’Kane M. The reporting, classification and grading of quality failures in the medical laboratory. Clin Chim Acta 2009;404: 28–31.10.1016/j.cca.2009.03.023Search in Google Scholar

3. BCPSLS. British Columbia Patient Safety and Learning System Annual Report, April 2010 – March 2011. Available at: http://bcpslscentral.ca/wp-content/uploads/2014/04/pslsannualreport1011.pdf. Accessed: 8 Dec 2014.Search in Google Scholar

4. Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin Biochem 2010;47:101–10.10.1258/acb.2009.009222Search in Google Scholar

5. Lippi G, Chance JJ, Church S, Dazzi P, Fontana R, Giavarina D, et al. Preanalytical quality improvement: from dream to reality. Clin Chem Lab Med 2011;49:1113–26.10.1515/CCLM.2011.600Search in Google Scholar

6. Hallowell M, Gambatese J. Construction safety risk mitigation. J Constr Eng Manage 2009;135:1316–23.10.1061/(ASCE)CO.1943-7862.0000107Search in Google Scholar

7. Dekker S. Safety differently: human factors for a new era, 2nd ed. Boca Raton, FL: CRC Press, 2014.10.1201/b17126Search in Google Scholar

8. Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol 2003;120:18–26.10.1309/8U5D0MA6MFH2FG19Search in Google Scholar

9. Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem 2007;53:1338–42.10.1373/clinchem.2007.088344Search in Google Scholar PubMed

10. Snydman LK, Harubin B, Kumar S, Chen J, Lopez RE, Salem DN. Voluntary electronic reporting of laboratory errors: an analysis of 37 532 laboratory event reports from 30 health care organizations. Am J Med Qual 2012;27:147–53.10.1177/1062860611413567Search in Google Scholar PubMed

11. Making Medical Lab Quality Relevant. Confidentiality and Laboratory Error. Available at: http://www.medicallaboratoryquality.com/2013/08/confidentiality-and-laboratory-error.html. Accessed: 8 Dec 2014.Search in Google Scholar

12. Global News. UPDATED: Personal health information breached through misdirected faxes. Available at: http://globalnews.ca/news/1087146/transgendered-person-medical-records-faxed-to-saskatchewan-school/. Accessed: 8 Dec 2014.Search in Google Scholar

13. Conceptual Framework for the International Classification of Patient Safety, Version 1.1. Final Technical Report, 2009.Search in Google Scholar

14. Pham JC, Gianci S, Battles J, Beard P, Clarke JR, Coates H, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care 2010;19:446–51.10.1136/qshc.2009.037739Search in Google Scholar PubMed

15. Hutchinson A, Young TA, Cooper KL, McIntosh A, Karnon JD, Scobie S, et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Qual Saf Health Care 2009;18:5–10.10.1136/qshc.2007.022400Search in Google Scholar PubMed

16. Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care 2002;11:76–80.10.1136/qhc.11.1.76Search in Google Scholar PubMed PubMed Central

17. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care’s ability to quantify and accurately measure harm reduction. J Patient Saf 2010;6:247–50.10.1097/PTS.0b013e3181fd1697Search in Google Scholar PubMed

18. Ritwik U. Risk-based approach to near miss. Hydrocarbon Process 2002;81:93–6.Search in Google Scholar

19. Dovey SM, Wallis KA. Incident reporting in primary care: epidemiology or culture change? BMJ Qual Saf 2011;20:1001–3.10.1136/bmjqs-2011-000465Search in Google Scholar PubMed

20. O’Hagan J, MacKinnon NJ, Persaud D, Etchegary H. Self-reported medical errors in seven countries: implications for Canada. Healthc Q 2009;12 Spec No Patient:55–61.10.12927/hcq.2009.20967Search in Google Scholar PubMed

21. Schwappach DL. Risk factors for patient-reported medical errors in eleven countries. Health Expect 2014;17:321–31.10.1111/j.1369-7625.2011.00755.xSearch in Google Scholar PubMed PubMed Central

22. Hincapie AL, Slack M, Malone DC, MacKinnon NJ, Warholak TL. Relationship between patients’ perceptions of care quality and health care errors in 11 countries: a secondary data analysis. Qual Manag Health Care 2016;25:13–21.10.1097/QMH.0000000000000079Search in Google Scholar PubMed PubMed Central

Received: 2017-3-15

Accepted: 2017-5-8

Published Online: 2017-5-23

Published in Print: 2017-6-27

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Articles in the same Issue

https://doi.org/10.1515/dx-2017-0013

Keywords for this article

laboratory error; patient safety; post-analytical; pre-analytical; quality; reporting system