Laboratory Blunders Revisited

Abstract

SUMMARY. Blunders which occurred over a 1 year period in the clinical chemistry departments of two health districts were recorded and categorized according to type and detection stage. A blunder was defined as an incident leading to an incorrect result/set of results either being reported or detected at the final checking-out stage in the laboratory. Of the total of 120 blunders-which is a blunder rate of less than 0'1 % of requests-53 (440/0) were detected at the final checking-out stage. Blunders detected after the report had left the laboratory were divided into those subsequently picked up by laboratory personnel (23); those detected by clinicians (19); and those by external quality assessment schemes (21). The types of blunder were fairly equally distributed between the booking-in (36), analysis (38), and reporting (35) stages of the laboratory process. A formal review of blunders detected in laboratories is a valuable aid to overall performance. Additional key phrases: quality assurance; errors; analysisDespite passing interest during each of the three last decades in 'blunders' occurring in clinical chemistry laboratories, the situation remains as Northam! described it in 1977, namely 'that although much effort and expense is being devoted to the assessment of analytical variation, little attention has been directed to the detection of laboratory blunders'.That seriously addressing the issue of laboratory blunders has not occurred is surprising, because the most recent study-reported a rate of O' 3% in a large laboratory. Although this figure represented a significant improvement over the rate of 2'3% found by McSwiney and Woodrow;' it does imply that at least two serious errors occur each working day in large laboratories.To investigate the current situation, the South East Thames Quality Assurance Group decided to monitor the number, type and detection stage of blunders which were picked-up over a 1 year period in each of two health districts.Correspondence: Mrs R Lapworth. METHODA blunder was defined as an incident leading to an incorrect result/set of results either being reported or detected at the final checking-out stage in the laboratory. Errors detected before or during analysis, or before the final validation stage were not included. The staff in each laboratory were informed that the study was being carried out and agreed to bring any blunders that occurred to our attention. Details of these, and at what stage the blunder was detected were recorded by ourselves or occasionally by other senior laboratory staff. The blunders were then categorized according to type and detection stage.Blunders which affected samples distributed by the external quality assessment schemes (EQAS) during the period of this study were included if the results were more than three standard deviations (SD) from the method mean. The blunder rate affecting EQAS samples was also calculated separately as they may give a better estimate of the true detection rate.?Users of the service were not specifically asked to bring blun...

Frequency of Problems During Clinical Molecular-Genetic Testing

“…I2 In Italy, an error rate of 0.47% was found in the "stat" section of a university laboratory 9 ; and a blunder rate of approximately 0.05% was reported for 2 clinical chemistry departments in England. 13 These error rates appear roughly comparable to those observed in our study, although direct comparison is problematic because some studies did not exclude minor errors or used mainly highly automated equipment to perform tests. 9 ' 3 In New York State in 1984, adverse events occurred in 3.7% of hospitalizations.…”

Error tracking in a clinical biochemistry laboratory

“…However, the largest number of errors arose from outside the laboratory, possibly as a result of a lack of focus and experience. The error rate of 1 in 142 patients, or 1 per 1223 tests, in this study is within the same order of magnitude as that reported for general laboratories (4,5), and it is slightly higher than those reported for two clinical chemistry laboratories (10). The frequency was lower than that reported from ''STAT'' laboratory sections (11,12).…”

Errors in pathology and laboratory medicine: Consequences and prevention

“…The distribution of errors in the study was the following: preanalytical 60.2%, analytical 13.3%, and post-analytical 18.5%. A review study evaluating several reports of errors in laboratory medicine also found that most errors occur in the pre-analytical phase [8], which differs from the similar distribution of errors among the three phases reported by Lapworth and Teal [79].…”

“…The denominator was the number of test results reported during the time interval. Lapworth and Teal reported a rate of error of 0.05% [79]. For this study, an error was defined as an incident leading to an incorrect result/set of results either being reported or detected at the final checking-out stage in the laboratory.…”