title: Laboratory Errors in a Pediatric Emergency Department Network: An Analysis of Incident Reports.
abstract: OBJECTIVE
  To describe the types and severity of reported laboratory errors in pediatric emergency departments.
  
  
  METHODS
  Retrospective review of incident reports classified as laboratory errors from July 2007 to June 2008 within the Pediatric Emergency Care Applied Research Network. Laboratory testing errors recorded included: delayed results or lost specimen, unlabeled specimens, wrong patient, failure to label specimen correctly, and other. The severity of laboratory-related incidents was characterized using the National Coordinating Council for Medication Error Reporting and Prevention severity classification system. Contributing factors were classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems-based.
  
  
  RESULTS
  A total of 335 (42.2%) laboratory reports were related to events in the preanalytic phase. Involved staff personnel were identified in 345 of the reports (43.5%). Nurses were identified in 179 (22.6%) and physicians in 38 (4.8%). The majority of laboratory errors [408 (51.5%)] were not associated with harm; 138 (17.4%) patients were harmed by the error; 136 (98.6%) patients were temporarily harmed and required treatment, and 1 (0.7%) patient was hospitalized or had their hospitalization prolonged with the event. Human factors 657 (82.8%) were the most common contributing factor.
  
  
  CONCLUSIONS
  Laboratory errors are a common cause of safety events in the pediatric ED. Most events are preanalytic and involve problems with specimens that are improperly collected, mislabeled, or lost. Although most events were not associated with harm, there is potential for significant injury.
authors.affiliation: From the *Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD; †Department of Emergency Medicine Children's National Medical Center, Washington, DC; ‡Department of Pediatrics, University of Utah, Salt Lake City, UT; §Lewis M. Fraad, Department of Pediatrics (Emergency Medicine), Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY; ∥Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; ¶Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and #Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI.
authors.forename: Richard
authors.initials: R
authors.lastname: Lichenstein
authors.forename: Karen
authors.initials: K
authors.lastname: O'Connell
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Funai
authors.forename: Stephen
authors.initials: S
authors.lastname: Blumberg
authors.forename: Kathy
authors.initials: K
authors.lastname: Shaw
authors.forename: Richard
authors.initials: R
authors.lastname: Ruddy
authors.forename: Prashant V
authors.initials: PV
authors.lastname: Mahajan
authors.forename: James M
authors.initials: JM
authors.lastname: Chamberlain
mesh_terms: D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards / Q000706:statistics & numerical data; D019300:Medical Errors / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D013048:Specimen Handling