Classifying laboratory incident reports to identify problems that jeopardize patient safety.
We developed a laboratory incident report classification system that can guide reduction of actual and potential adverse events. The system was applied retrospectively to 129 incident reports occurring during a 16-month period. Incidents were classified by type of adverse event (actual or potential), specific and potential patient impact, nature of laboratory involvement, testing phase, and preventability. Of 129 incidents, 95% were potential adverse events. The most common specific impact was delay in receiving test results (85%). The average potential impact was 2.9 (SD, 1.0; median, 3; scale, 1-5). The laboratory alone was responsible for 60% of the incidents; 21% were due solely to problems outside the laboratory's authority. The laboratory function most frequently implicated in incidents was specimen processing (31%). The preanalytic testing phase was involved in 71% of incidents, the analytic in 18%, and the postanalytic in 11%. The most common preanalytic problem was specimen transportation (16%). The average preventability score was 4.0 (range, 1-5; median, 4; scale, 1-5), and 94 incidents (73%) were preventable (score, 3 or more). Of the 94 preventable incidents, 30% involved cognitive errors, defined as incorrect choices caused by insufficient knowledge, and 73% involved noncognitive errors, defined as inadvertent or unconscious lapses in expected automatic behavior.
Astion
Michael L
ML
Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA.
Shojania
Kaveh G
KG
Hamill
Tim R
TR
Kim
Sara
S
Ng
Valerie L
VL
D006751:Hospital Information Systems; D006785:Hospitals, University; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control; D005791:Patient Care; D012189:Retrospective Studies; D012308:Risk Management / Q000145:classification* / Q000379:methods; D012449:Safety; D013048:Specimen Handling