System-related and cognitive errors in laboratory medicine
-
Mario Plebani
Abstract
Current efforts focusing on better defining the prevalence of diagnostic errors, their causes and remediation strategies should address the role of laboratory testing and its contribution to high-quality care as well as a possible source of diagnostic errors. Data collected in the last few years highlight the vulnerability of extra-analytical phases of the testing cycle and the need for programs aiming to improve all steps of the process. Further studies have clarified the nature of laboratory-related errors, namely the evidence that both system-related and cognitive factors account for most errors in laboratory medicine. Technology developments are effective in decreasing the rates of system-related errors but organizational issues play a fundamental role in assuring a real improvement in quality and safety in laboratory processes. Educational interventions as well as technology-based interventions have been proposed to reduce the risk of cognitive errors. However, to reduce diagnostic errors and improve patient safety, clinical laboratories have to embark on a paradigmatic shift restoring the nature of laboratory services as an integral part of the diagnostic and therapy process.
Author contributions: The author has 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. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington (DC): National Academies Press (US), 2000.Suche in Google Scholar
2. Balogh EP, Miller BT, Ball JR. Improving diagnosis in health care. Washington (DC): National Academies Press (US), 2015.10.17226/21794Suche in Google Scholar
3. Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf 2012;21:535–57.10.1136/bmjqs-2011-000149Suche in Google Scholar
4. Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf 2014;40:102–10.10.1016/S1553-7250(14)40013-8Suche in Google Scholar
5. Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2005;31:106–13.10.1016/S1553-7250(05)31015-4Suche in Google Scholar
6. Lundberg GD. Acting on significant laboratory results [editorial]. J Am Med Assoc 1981;245:1762–3.10.1001/jama.1981.03310420052033Suche in Google Scholar PubMed
7. Plebani M, Laposata M, Lundberg GD. The brain-to-brain loop concept for laboratory testing 40 years after its introduction. Am J Clin Pathol 2011;136:829–33.10.1309/AJCPR28HWHSSDNONSuche in Google Scholar PubMed
8. Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med 2016;54:1881–91.10.1515/cclm-2016-0848Suche in Google Scholar PubMed
9. Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chim Acta 2009;404:16–23.10.1016/j.cca.2009.03.022Suche in Google Scholar PubMed
10. Plebani M, Carraro P. Mistakes in a stat laboratory: types and frequency. Clin Chem 1997;43:1348–51.10.1093/clinchem/43.8.1348Suche in Google Scholar
11. Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin Biochem 2010;47:101–10.10.1258/acb.2009.009222Suche in Google Scholar PubMed
12. Plebani M. Quality in laboratory medicine: 50 years on. Clin Biochem 2017;50:101–4.10.1016/j.clinbiochem.2016.10.007Suche in Google Scholar PubMed
13. Plebani M. Laboratory-associated and diagnostic errors: a neglected link. Diagnosis (Berl) 2014;1:89–94.10.1515/dx-2013-0030Suche in Google Scholar PubMed
14. Restelli V, Taylor A, Cochrane D, Noble MA. Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system. Diagnosis (Berl) 2017;4:79–86.10.1515/dx-2017-0013Suche in Google Scholar PubMed
15. Piva E, Tosato F, Plebani M. Pre-analytical phase: the automated ProTube device supports quality assurance in the phlebotomy process. Clin Chim Acta 2015;451:287–91.10.1016/j.cca.2015.10.010Suche in Google Scholar PubMed
16. Plebani M, Astion ML, Barth JH, Chen W, de Oliveira Galoro CA, Escuer MI, et al. Harmonization of quality indicators in laboratory medicine. A preliminary consensus. Clin Chem Lab Med 2014;52:951–8.10.1515/cclm-2014-0142Suche in Google Scholar PubMed
17. Plebani M; EFLM Task Force on performance specifications for the extra-analytical phases. Performance specifications for the extra-analytical phases of laboratory testing: why and how. Clin Biochem 2017;50:550–4.10.1016/j.clinbiochem.2017.02.002Suche in Google Scholar PubMed
18. Epner PL. Appraising laboratory quality and value: what’s missing? Clin Biochem 2017;50:622–4.10.1016/j.clinbiochem.2017.04.013Suche in Google Scholar PubMed
19. International Organization for Standardization (ISO). Medical laboratories – particular requirements for quality and competence. ISO 15189, Geneva, Switzerland, 2012.Suche in Google Scholar
20. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med 2009;169:1881–7.10.1001/archinternmed.2009.333Suche in Google Scholar PubMed
21. Laposata M. Obtaining a correct diagnosis rapidly in the United States is associated with many barriers not present in other countries. Am J Clin Pathol 2018;149:458–60.10.1093/ajcp/aqy010Suche in Google Scholar PubMed
22. Hickner J, Thompson PJ, Wilkinson T, Epner P, Sheehan M, Pollock AM, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med 2014;27:268–74.10.3122/jabfm.2014.02.130104Suche in Google Scholar PubMed
23. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145:488–96.10.7326/0003-4819-145-7-200610030-00006Suche in Google Scholar PubMed
24. Kachalia A, Gandhi TK, Pupolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the Emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196–205.10.1016/j.annemergmed.2006.06.035Suche in Google Scholar PubMed
25. Hickner J, Graham DG, Elder NC, Brandt E, Emsermann CB, Dovey S, et al. Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network. Qual Saf Health Care 2008;17:194–200.10.1136/qshc.2006.021915Suche in Google Scholar PubMed
26. Blumenthal D. The errors of our ways. Clin Chem 1997;43:1305.10.1093/clinchem/43.8.1305Suche in Google Scholar
27. Fryer AA, Smellie WS. Managing demand for laboratory tests: a laboratory toolkit. J Clin Pathol 2013;66:62–72.10.1136/jclinpath-2011-200524Suche in Google Scholar PubMed
28. Janssens PM. Managing the demand for laboratory testing: options and opportunities. Clin Chim Acta 2010;411: 1596–602.10.1016/j.cca.2010.07.022Suche in Google Scholar PubMed
29. Rubistein M, Hirsch R, Bandyopadhyay K, Madison B, Taylor T, Ranne A, et al. Effectiveness of practice to support appropriate laboratory test utilization. Am J Clin Pathol 2018;149:197–221.10.1093/ajcp/aqx147Suche in Google Scholar PubMed PubMed Central
30. Brush JE, Brophy JM. Sharing the process of diagnostic decision making. JAMA Int Med 2017;177:1245–6.10.1001/jamainternmed.2017.1929Suche in Google Scholar PubMed
31. Dickerson JA, Fletcher AH, Procop G, Keren D, Singh IR, Garcia JJ, et al. Transforming laboratory utilization review into laboratory stewardship: guidelines by the PLUGS National Committee for Laboratory Stewardship. J Appl Lab Med 2017;2:259–68.10.1373/jalm.2017.023606Suche in Google Scholar PubMed
32. Cifu AS. Diagnostic errors and diagnostic calibration. J Am Med Assoc 2017;318:905–6.10.1001/jama.2017.11030Suche in Google Scholar PubMed
33. Cook DA, Sherbino J, Durning SJ. Management reasoning. J Am Med Assoc 2018;319:2267–8.10.1001/jama.2018.4385Suche in Google Scholar PubMed
34. Plebani M. Clinical laboratories: production industry or medical services? Clin Chem Lab Med 2015;53:995–1004.10.1515/cclm-2014-1007Suche in Google Scholar PubMed
35. Plebani M. Clinical laboratory: bigger is not always better. Diagnosis 2018;5:41–6.10.1515/dx-2018-0019Suche in Google Scholar PubMed
©2018 Walter de Gruyter GmbH, Berlin/Boston
Artikel in diesem Heft
- Frontmatter
- Editorials
- Learning from tragedy – improving diagnosis through case reviews
- Diagnostic test accuracy: a valuable tool for promoting quality and patient safety
- Review
- Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?
- Opinion Paper
- System-related and cognitive errors in laboratory medicine
- Original Articles
- The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners
- Determining qualitative effect size ratings using a likelihood ratio scatter matrix in diagnostic test accuracy systematic reviews
- Patient groups, clinicians and healthcare professionals agree – all test results need to be seen, understood and followed up
- Teaching about diagnostic errors through virtual patient cases: a pilot exploration
- Using computerized virtual cases to explore diagnostic error in practicing physicians
- “Closing the loop”: a mixed-methods study about resident learning from outcome feedback after patient handoffs
- Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty
- Letters to the Editor
- Capturing diagnostic errors in incident reporting systems: value of a specific “DX Tile” for diagnosis-related concerns
- PSA-based, prostate cancer risk on-line calculators: no such thing as a crystal ball?
- Learning from Error
- Learning from tragedy: the Julia Berg story
- Acknowledgment
- Congress Abstracts
- Diagnostic Error in Medicine
Artikel in diesem Heft
- Frontmatter
- Editorials
- Learning from tragedy – improving diagnosis through case reviews
- Diagnostic test accuracy: a valuable tool for promoting quality and patient safety
- Review
- Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?
- Opinion Paper
- System-related and cognitive errors in laboratory medicine
- Original Articles
- The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners
- Determining qualitative effect size ratings using a likelihood ratio scatter matrix in diagnostic test accuracy systematic reviews
- Patient groups, clinicians and healthcare professionals agree – all test results need to be seen, understood and followed up
- Teaching about diagnostic errors through virtual patient cases: a pilot exploration
- Using computerized virtual cases to explore diagnostic error in practicing physicians
- “Closing the loop”: a mixed-methods study about resident learning from outcome feedback after patient handoffs
- Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty
- Letters to the Editor
- Capturing diagnostic errors in incident reporting systems: value of a specific “DX Tile” for diagnosis-related concerns
- PSA-based, prostate cancer risk on-line calculators: no such thing as a crystal ball?
- Learning from Error
- Learning from tragedy: the Julia Berg story
- Acknowledgment
- Congress Abstracts
- Diagnostic Error in Medicine
