The detection and prevention of errors in laboratory medicine
Top Cited Papers
Open Access
- 1 December 2009
- journal article
- review article
- Published by SAGE Publications in Annals of Clinical Biochemistry: International Journal of Laboratory Medicine
- Vol. 47 (2), 101-110
- https://doi.org/10.1258/acb.2009.009222
Abstract
The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories. Evidence demonstrates that pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. Most errors are identified in pre-pre-analytic and post-post-analytic steps outside of the laboratory. In a patient-centred approach to the delivery of health-care services, there is the need to investigate, in the TTP, any possible defect that may have a negative impact on the patient. 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/testing error) or non-laboratory operator (e.g. inappropriate test request, error in patient identification and/or blood collection). Patient misidentification and problems communicating results, which affect the delivery of diagnostic services, are recognized as the main goals for quality improvement. International initiatives aim at improving these aspects. Grading laboratory errors on the basis of their seriousness should help identify priorities for quality improvement and encourage a focus on corrective/preventive actions. It is important to consider not only the actual patient harm sustained but also the potential worst-case outcome if such an error were to reoccur. The most important lessons we have learned are that system theory also applies to laboratory testing and that errors and injuries can be prevented by redesigning systems that render it difficult for all health-care professionals to make mistakes.This publication has 65 references indexed in Scilit:
- Keeping the Patient in the Equation — Humanism and Health Care ReformThe New England Journal of Medicine, 2009
- Interference from endogenous antibodies in automated immunoassays: what laboratorians need to knowJournal of Clinical Pathology, 2009
- Evaluation of Effectiveness of a Computerized Notification System for Reporting Critical ValuesAmerican Journal of Clinical Pathology, 2009
- Factitious Biochemical Measurements Resulting From Hematologic ConditionsAmerican Journal of Clinical Pathology, 2009
- Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research NetworkHeart, 2008
- The frequency of missed test results and associated treatment delays in a highly computerized health systemBMC Family Practice, 2007
- The Quality of Laboratory Testing TodayAmerican Journal of Clinical Pathology, 2006
- Cytologic Grade Independently Predicts Survival of Patients With Pancreatic AdenocarcinomaAmerican Journal of Clinical Pathology, 2005
- Is it safe to have a laboratory test?Accreditation and Quality Assurance, 2004
- Preventing Problems, Medical Errors, and Biohazards in Point-of-Care TestingPoint of Care: The Journal of Near-Patient Testing & Technology, 2003