title: Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.
abstract: Laboratory testing is essential for diagnosis, evaluation, and management. The objective was to describe the type of laboratory events reported in hospitals using a voluntary electronic error reporting system (e-ERS) via a cross-sectional analysis of reported laboratory events from 30 health organizations throughout the United States (January 1, 2000, to December 31, 2005). A total of 37,532 laboratory-related events were reported, accounting for 14.1% of all reported quality events. Preanalytic laboratory events were the most common (81.1%); the top 3 were specimen not labeled (18.7%), specimen mislabeled (16.3%), and improper collection (13.2%). A small number (0.08%) of laboratory events caused permanent harm or death; 8% caused temporary harm. Most laboratory events (55%) did not cause harm. Laboratory errors constitute 1 of 7 quality events. Laboratory errors often are caused by events that precede specimen arrival in the lab and should be preventable with a better labeling processes and education. Most laboratory errors do not lead to patient harm.
authors.affiliation: Tufts Medical Center, Boston, MA 02111, USA.
authors.forename: Laura K
authors.initials: LK
authors.lastname: Snydman
authors.forename: Beth
authors.initials: B
authors.lastname: Harubin
authors.forename: Sanjaya
authors.initials: S
authors.lastname: Kumar
authors.forename: Jack
authors.initials: J
authors.lastname: Chen
authors.forename: Robert E
authors.initials: RE
authors.lastname: Lopez
authors.forename: Deeb N
authors.initials: DN
authors.lastname: Salem
mesh_terms: D003430:Cross-Sectional Studies; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards / Q000706:statistics & numerical data; D019300:Medical Errors / Q000009:adverse effects / Q000145:classification / Q000706:statistics & numerical data*; D061214:Patient Safety / Q000706:statistics & numerical data; D013048:Specimen Handling / Q000009:adverse effects; D014481:United States / Q000453:epidemiology; D035141:Voluntary Programs / Q000706:statistics & numerical data