Laboratory error reporting rates can change significantly with year-over-year examination

Noble, Michael A.; Restelli, Veronica; Taylor, A. E.; Cochrane, Douglas

doi:10.1515/dx-2017-0043

Cited by 4 publications

(5 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

Section: Discussionsupporting

confidence: 91%

“…Our finding that most errors occur in the preanalytical testing phase (77.1%) is consistent with the results from the study by Snydman et al 13 (81.1%) and the studies of group of Noble (69.1%). 14,15 Preanalytical events range from 62% to 88% in other studies in which data from other sources than incident reports were used. 6,10,20 In our study, 13.5% of the events are related to the analytical phase, and this is consistent with literature in which 11% to 18% of the events could be related to the analytical phase.…”

Section: Human Wrong Diagnosis Unidentifiablementioning

confidence: 99%

“…Databases with voluntary incident reports have not been widely used yet for investigating errors in laboratory testing process. We are familiar with 3 large studies, performed in the United States and Canada 13–15 . In the first study, an analysis of 37,532 laboratory event reports, it was found that most errors occurred in the preanalytical phase (specimen not labeled/mislabeled and improper collection) and that most errors did not cause harm 13 .…”

mentioning

confidence: 99%

“…We are familiar with 3 large studies, performed in the United States and Canada. [13][14][15] In the first study, an analysis of 37,532 laboratory event reports, it was found that most errors occurred in the preanalytical phase (specimen not labeled/mislabeled and improper collection) and that most errors did not cause harm. 13 In the second study, an analysis of 12,278 laboratory related safety events reported to the British Columbia Patient Safety and Learning System, comparable results were found.…”

mentioning

confidence: 99%

“…The third study from the same group with data from British Columbia Patient Safety and Learning System confirmed the findings from their first study. 15 To gain more insight into diagnostic errors related to errors in the clinical laboratory testing process, we conducted a retrospective analysis of voluntary incident reports in our hospital, a large academic teaching hospital with high volume diagnostic testing (e.g., approximately 500,000 orders for clinical chemistry testing annually) in which we looked at the phases of the testing process, the type of errors, the causes and the clinical impact, including potential diagnostic errors, as well as the relation between these.…”

mentioning

confidence: 99%

See 4 more Smart Citations

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error: A Voluntary Incident Report Analysis

van Moll,

Egberts,

Wagner

et al. 2023

J Patient Saf

View full text Add to dashboard Cite

Objectives Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process. Methods We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017–2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error. Results Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%). Conclusions Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.

show abstract

Section: Discussionsupporting

confidence: 91%