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Effect of Lab Errors on Patient Care
Prof. Dr.Asim Mumtaz Shalamar Medical & Dental College Lahore
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Patient & Health care team
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“To Err is Human” Building a Safer Health System
Institute of Medicine : 1999 8th Leading cause of death 44000 – 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.
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60% to 80% of patient management decisions are based on lab data
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IMPACT ON PATIENT Psychological Trauma Wrong Diagnosis Delay in
Treatment Legal Issues Inappropriate Monitoring Wastage of Resources Prolonged hospital stay Financial burden
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Laboratory Medicine Every sample is a PATIENT
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Why Do Lab Errors Occur ? 22 Clinicians 10 Surgeons 6 Paediatricians
12 Pathologists
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Answer “Lab errors mostly occur due to instrument malfunctioning or wrong reporting…”
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Frequency of Lab Errors
46 – 68% Preanalytical 8 – 17 % Analytical 18 – 47% Postanalytical Effects of pre analytical errors on quality of laboratory medicine : J Clin Biochem. 2010; 26(1): Errors in medicine and errors in laboratory medicine: What is difference? Blood transfuse. 2010; 8:79-81.
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TYPES OF LAB ERRORS Analytical Postanalytical Preanalytical
LATENT ERROR ACTIVE ERROR
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Latent & Active Errors Latent Errors Active Errors
poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations Active Errors occur at the level of the frontline operator effects are felt almost immediately
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Examples of Latent Errors in Lab
IT Lack of instrument interface with LIS Equipment Main 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. Staffing Chronic understaffing on evening and night shifts leads to high error rate. leads to many active data entry errors leading to long delays when the instrument is down
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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
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Preanalytical Variables
Sample Accessioning in Lab Water Bath Temperature variation Centrifugation Wrong Labeling of tubes for analysis Inappropriate Storage of samples
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Analytical Variables Instrument Error-Malfunctioning
Improper Calibration Pipetting error Lack of specificity of method
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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)
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Frequency of Errors (Six Months Data)
Variable Private 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)
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Frequency of Errors (Six Months Data)
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
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Pre Analytical Errors
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Effect of Haemolysis on Tests
INCREASED ALT AST LDH CK Lipase Mg Creatinine Potassium Phosphate Urea, protein Iron, Ammonia DECREASED Bilirubin Insulin Albumin
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Effect of Lipaemia INCREASED DECREASED Glucose
Phosphorus Bilirubin Uric acid Total protein HbA1c Fructosamine Triglycerides D-dimer ALT/ AST DECREASED Sodium (pseudohyponatremia) HDL cholesterol Ceruloplasmin Prealbumin Transferrin
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Interchange of samples
Effect of Pre Analytical Error : Wrong Identification Public Sector Hospital Lab Patient Name: Sadiq Ahmad Age: 65 yrs Ward: Male Medical Date: MR #: Tests requested: Blood Sugar Fasting LFTs Patient Name: Mr. Sadiq Age: 62 yrs Ward: Male Medical Date: MR #: Tests requested: LFTs RFTs Anti HCV HBsAg Interchange of samples
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Impact on Patient Delay in diagnosis Delay in treatment
Prolonged hospital stay Wastage of resources Patient inconvenience (Repeat Fasting)
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Effect of Analytical Error Example : Public Sector Hospital Lab
Patient Name: B/O ABC Age: 6 Days Ward: Peads MR #: Test Requested: Bilirubin Total mg/dl 17 mg/dl 21.5 mg/dl Consequence: Disparity in result EXCHNAGE TRANSFUSION ?
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Effect of Post Analytical Error Example Private Hospital Lab
Patient Name: Iftikhar Age: 35 yrs Ward: Emergency MR #: Test Requested: Trop I Result Reported: ng/ml Actual Result: ng/ml Consequence: Hospital admission financial burden Psychological trauma to the patient
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How To Improve
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Error Identification Error Identification & Documentation Q Probes
Q Track Continuous monitoring
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What we can do? Implementation of systematic error tracking system in daily practice
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Training & Monitoring Training of the Nursing Staff
Continuous Training & Monitoring of Lab Staff SOP & Sample Rejection Criteria
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Internal Quality Control Program External Quality Control Program
Quality Assurance Program Internal Quality Control Program External Quality Control Program Certification & Accreditation
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LIS & HIS Interpretation & Monitoring of Reports Main Analysers – LIS
Availability of reports on HIS
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How To Gain Strength Policies & Procedures Commitment Communication
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Thank You
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