Dig Deeper: A Case Report of Finding (and Fixing) the Root Cause of Add-On Laboratory Failures

Appl Clin Inform. 2022 Aug;13(4):874-879. doi: 10.1055/a-1913-4158. Epub 2022 Jul 29.


Background: Venipunctures and the testing they facilitate are clinically necessary, particularly for hospitalized patients. However, excess venipunctures lead to patient harm, decreased patient satisfaction, and waste.

Objectives: We sought to identify contributors to excess venipunctures at our institution, focusing on electronic health record (EHR)-related factors. We then implemented and evaluated the impact of an intervention targeting one of the contributing factors.

Methods: We employed the quality improvement (QI) methodology to find sources of excess venipunctures, specifically targeting add-on failures. Once an error was identified, we deployed an EHR-based intervention which was evaluated with retrospective pre- and postintervention analysis.

Results: We identified an error in how the EHR evaluated the ability of laboratories across a health system to perform add-on tests to existing blood specimens. A review of 195,263 add-on orders placed prior to the intervention showed that 165,118 were successful and 30,145 failed, a failure rate of 15.4% (95% confidence interval [CI]: 15.1-15.6). We implemented an EHR-based modification that changed the criteria for add-on testing from a health-system-wide query of laboratory capabilities to one that incorporated only the capabilities of laboratories with feasible access to existing patient samples. In the 6 months following the intervention, a review of 87,333 add-on orders showed that 77,310 were successful, and 10,023 add-on orders failed resulting in a postintervention failure rate of 11.4% (95% CI: 11.1, 11.8) (p < 0.001).

Conclusion: EHR features such as the ability to identify possible add-on tests are designed to reduce venipunctures but may produce unforeseen negative effects on downstream processes, particularly as hospitals merge into health systems using a single EHR. This case report describes the successful identification and correction of one cause of add-on laboratory failures. QI methodology can yield important insights that reveal simple interventions for improvement.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Electronic Health Records*
  • Humans
  • Laboratories*
  • Patient Satisfaction
  • Quality Improvement
  • Retrospective Studies

Grants and funding

Funding None.