Error tracking in a clinical biochemistry laboratory.
BACKGROUND
We report our results for the systematic recording of all errors in a standard clinical laboratory over a 1-year period.


METHODS
Recording was performed using a commercial database program. All individuals in the laboratory were allowed to report errors. The testing processes were classified according to function, and errors were classified as pre-analytical, analytical, post-analytical, or service-related, and then further divided into descriptive subgroups. Samples were taken from hospital wards (38.6%), outpatient clinics (25.7%), general practitioners (29.4%), and other hospitals.


RESULTS
A total of 1189 errors were reported in 1151 reports during the first year, corresponding to an error rate of 1 error for every 142 patients, or 1 per 1223 tests. The majority of events were due to human errors (82.6%), and only a few (4.3%) were the result of technical errors. Most of the errors (81%) were pre-analytical. Of the remainder, 10% were analytical, 8% were post-analytical, and 1% was service-related. Nearly half of the errors (n=550) occurred with samples received from general practitioners or clinical hospital wards. Identification errors were relatively common when non-technicians collected blood samples.


CONCLUSIONS
Each clinical laboratory should record errors in a structured manner. A relation database is a useful tool for the recording and extraction of data, as the database can be structured to reflect the workflow at each individual laboratory.
Szecsi
Pal Bela
PB
Department of Clinical Biochemistry, University of Copenhagen, Roskilde Hospital, Roskilde, Denmark. palsze01@geh.regionh.dk
Ødum
Lars
L
D001671:Biochemistry / Q000379:methods* / Q000592:standards; D002624:Chemistry, Clinical / Q000379:methods* / Q000592:standards; D016208:Databases, Factual; D006801:Humans; D007753:Laboratories / Q000592:standards; D012107:Research Design; D012984:Software