Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system

Diagnosis (Berl). 2017 Jun 27;4(2):79-86. doi: 10.1515/dx-2017-0013.

Abstract

Background: This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System.

Methods: The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported.

Results: Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences.

Conclusions: It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.

Keywords: laboratory error; patient safety; post-analytical; pre-analytical; quality; reporting system.

MeSH terms

  • British Columbia
  • Hospital Units
  • Humans
  • Laboratories, Hospital / organization & administration*
  • Medical Errors / statistics & numerical data*
  • Near Miss, Healthcare
  • Online Systems*
  • Patient Safety*
  • Retrospective Studies
  • Risk Management / methods*
  • Volunteers*