Laboratory blunders revisited.
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 (44%) 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.
Lapworth
R
R
Department of Clinical Chemistry, William Harvey Hospital, Ashford, Kent, UK.
Teal
T K
TK
D002624:Chemistry, Clinical / Q000592:standards*; D007755:Laboratories, Hospital / Q000592:standards*; D011786:Quality Control; D015203:Reproducibility of Results