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