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ECRI report Laboratory errors happen most often outside the lab

Most laboratory errors happen outside the lab, ECRI report finds

By Sabriya Rice
Posted: April 17, 2014 - 2:00 pm ET

Laboratory errors don't necessarily originate in the lab itself, contrary to what many hospitals might think, according to a new ECRI Institute patient-safety report (PDF) studying the impact of lab-testing errors in the clinical setting. This misperception can have serious consequences because those who work outside the laboratory may not recognize their role in the issue, the report warned.

“Organizations that reported events for this analysis often misrepresented these incidents as originating in the laboratory,” the study said. “As organizations work to identify solutions to prevent laboratory errors, they must first overcome the misperceptions and misunderstandings about laboratory testing.”

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The ECRI Institute evaluated 2,420 mistakes that occurred between 2011 and mid-2013; 52 hospitals voluntarily submitted laboratory and radiology events to the group's safety-event reporting system. Only 4% of reported potentially harmful errors actually occurred in the laboratory, according to the report. However, hospitals who submitted events attributed errors to the laboratory setting 25% of the time.

Close to 75% of mistakes occurred in the pre-analytic stage, which ECRI Institute defined as the time frame in which tests are selected and ordered, specimens are identified and transported, and patients are prepared. These mistakes were more likely to be associated with labels that had the wrong patient's name, the wrong specimen ordered, and incomplete or missing information.

The other 22% of mistakes occurred in the post-analytic stage, when results were interpreted, reported or stored. Negative events were associated with either missing results, or a delay in getting results to the staff member who ordered them.

Some hospitals also voluntarily reported the severity of their events, which they determined using the National Coordinating Council for Medication Error Reporting and Prevention's “harm score (PDF).” Events are ranked in a range from “A” (events that had the capacity to cause error but did not) to “I” (events that may have contributed to, or resulted in, a patient's death).

Of the 1,011 harm scores reported, none led to errors resulting in death, life-sustaining measures or permanent patient harm, but 28 events may have led to a temporary harm, for which the patient required an intervention or prolonged hospitalization. The majority of events were caught before harm was caused to the patient.

The report offered various recommendations, including prohibiting the “no news is good news” approach to test-results reporting; breaking down silos between care units and the lab; and conducting an event analysis to identify process breakdowns, among other recommendations.

“These are system-related issues that involve the organization, its policies and procedures, its staff members and their approaches to teamwork and communication,” the report said. This is the third “deep dive” the ECRI institute has done; in 2011 it delved into medication safety-related events, and in 2013 it investigated health information technology-related events.

When errors are discovered, they can be traumatic for those affected, the authors of the latest report said, since they can lead to a misdiagnosis which allows the patient's condition to worsen when lifesaving care could have been provided sooner.

Earlier this week, a study released in the journal BMJ Quality & Safety found that about 12 million U.S. adults could be misdiagnosed during outpatient visits annually, and nearly half of these errors had the potential to lead to worse patient outcomes.

“It's one thing to sound the alarm, but we're talking about potentially preventable misdiagnoses,” said safety expert Dr. David Newman-Toker, about the BMJ report. “There was a chance to do things differently,” he said.

Follow Sabriya Rice on Twitter: @MHSRice

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