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Prof. Dr.Asim MumtazShalamar Medical & Dental College Lahore
Effect of Lab Errors on Patient Care
Patient&
Health care team
“To Err is Human”
Building a Safer Health System
Institute of Medicine : 1999
8th Leading cause of death
44000 – 98000 deaths per year
Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human:Building a Safer Health System. Washington, DC: National Academies Press; 2000.
60% to 80% of patient management
decisions are based on lab data
Prolonged hospital
stay
Legal Issues
Psychological Trauma
Financial burden
Wrong Diagnosis
Wastage of Resources
Inappropriate Monitoring
Delay in Treatment
IMPACT ON PATIENT
Laboratory Medicine
Every sample is a PATIENT
Why Do Lab Errors Occur ?
22 Clinicians10 Surgeons 6 Paediatricians12 Pathologists
Answer
“Lab errors mostly occur due to
instrument malfunctioning or wrong
reporting…”
Frequency of Lab Errors
• 46 – 68% Preanalytical
• 8 – 17 %Analytica
l
• 18 – 47%Postanalytic
al
Errors in medicine and errors in laboratory medicine: What is difference? Blood transfuse. 2010; 8:79-81 .
Effects of pre analytical errors on quality of laboratory medicine : J Clin Biochem. 2010; 26(1): 46-49.
TYPES OF LAB ERRORS
Preanalytical
Analytical Postanalytical
LATENT ERROR
ACTIVE ERROR
Latent Errors poor design, incorrect installation, faulty
maintenance, bad management decisions, and poorly structured organizations
Active Errors occur at the level of the frontline operatoreffects are felt almost immediately
Latent & Active Errors
Examples of Latent Errors in Lab
IT Lack of instrument interface with LIS
EquipmentMain chemistry analyzer is overloaded and has no backup.
Work Environment
Culture of multitasking leads to error-prone environment
Policy and Procedures Flaws in Policies and procedures.
StaffingChronic understaffing on evening and night shifts leads to high error rate.
Preanalytical Variables
Voucher – Wrong entry
Patient Identification & Preparation
Physician Order Missed
Sample site selection & preparation
Improper venipuncture technique
Sample Labeling
Inappropriate Container
Delayed & Improper transport of Sample to lab
Preanalytical Variables
Sample Accessioning in Lab
Water Bath Temperature variation
Centrifugation
Wrong Labeling of tubes for analysis
Inappropriate Storage of samples
Analytical Variables
Instrument Error-Malfunctioning
Improper Calibration
Pipetting error
Lack of specificity of method
Postanalytical Variables
Wrong Entry of Test Results
Doctor/Ward Staff not informed about abnormal Results in time
Report Signed Without Confirming Result
Delayed turn around time (TAT)
Frequency of Errors (Six Months Data)
VariablePrivate
Hospital Lab
Public Sector Hospital Lab
Total Samples 127,500 90,000
Total No of Tests Performed 611,081 475,000
Total No. of Errors 1530 2540
Error Rate 1.2 % 2.82 %
Preanalytical 70.4% (1078) 56.7% (1440)
Analytical 12.1% (184) 14.9% (380)
Postanalytical 17.5% (268) 28.4% (720)
Phases Indoor Outdoor Total Errors
Preanalytical 784 (72.7%) 294 (27.2%) 1078
Analytical 103 (55.9%) 81 (44.02%) 184
Postanalytical 194 (72.3%) 74 (27.6%) 268
Frequency of Errors (Six Months Data)
Hemolysis61%
Wrong Vial15%
QNS8%
Wrong Labelling
4%
Clot in EDTA6%
Physician request order missed4%
Illegible Handwriting2%
Pre Analytical Errors
INCREASEDALT AST LDH CKLipase MgCreatinine PotassiumPhosphateUrea, proteinIron, Ammonia
DECREASEDBilirubin Insulin Albumin
Effect of Haemolysis on Tests
INCREASED• Glucose • Phosphorus • Bilirubin • Uric acid • Total protein • HbA1c
• Fructosamine • Triglycerides • D-dimer • ALT/ AST
DECREASED• Sodium
(pseudohyponatremia) • HDL cholesterol • Ceruloplasmin • Prealbumin • Transferrin
Effect of Lipaemia
Patient Name: Sadiq Ahmad Age: 65 yrs
Ward: Male Medical Date: 1-3-2011
MR #: 3003455
Tests requested:
1. Blood Sugar Fasting 2. LFTs
Patient Name: Mr. Sadiq Age: 62 yrs
Ward: Male Medical Date: 1-3-2011
MR #: 3003465
Tests requested: 1. LFTs
2. RFTs
3. Anti HCV
4. HBsAg
Effect of Pre Analytical Error : Wrong Identification Public Sector Hospital Lab
Interchange of samples
Delay in diagnosisDelay in treatmentProlonged hospital stayWastage of resourcesPatient inconvenience (Repeat Fasting)
Impact on Patient
Patient Name: B/O ABC Age: 6 Days Ward: Peads MR #:
2778333
Test Requested: Bilirubin Total
10-2-2011 12-2-2011 13-2-2011
19.5 mg/dl 17 mg/dl 21.5 mg/dl
Consequence: Disparity in result EXCHNAGE
TRANSFUSION ?
Effect of Analytical Error Example : Public Sector Hospital Lab
Patient Name: Iftikhar Age: 35 yrs
Ward: Emergency MR #: 2022556
Test Requested: Trop IResult Reported: 4.2 ng/mlActual Result: 0.42 ng/ml
Consequence: Hospital admission financial burden
Psychological trauma to the patient
Effect of Post Analytical Error Example Private Hospital Lab
How To Improve
Error Identification & Documentation
Q Probes
Q Track
Continuous monitoring
Error Identification
What we can do?
Implementation of systematic
error tracking system in daily
practice
Training of the Nursing Staff Continuous Training & Monitoring of Lab Staff
SOP & Sample Rejection Criteria
Training & Monitoring
Internal Quality Control Program
External Quality Control Program
Certification & Accreditation
Quality Assurance Program
Interpretation & Monitoring of Reports
Main Analysers – LIS
Availability of reports on HIS
LIS & HIS
How To Gain Strength
Policies & Procedures
Commitment
Communication
Thank You