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laboratoryerrorsCanwestopthem?Howdowestopthem?JohnStevenslaboratoryerrorsCanwestopthem?Howdowestopthem?JohnStevens

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laboratoryerrors

laboratoryerrorsmaybedefinedas"anydefectfromorderingteststoreportingresultsandappropriatelyinterpretingandreactingonthese",

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Lapworth&TealClinChem1yearStohletalWholeLab3yearsMcClellandandPhillips1994BMJTests9970006765643200000(units)Patients249000Errors12041351116inlaboratoryFrequency0.05%0.61%0.0000001875/unitPre31.6%75%Analytical31.6%16%Post30.8%9%

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Errorratesinclinicallaboratories

BoninietalClinicalChemistry2002Oneidentifiederrorevery

3350eventsMcSwineyandWoodrow(45)

50100eventsSouverijnetal.(46)

330eventsChambersetal.(47)

1000eventsBoone(48)

8300laboratoryresultsor2000patientsLapworthandTeal(10)

900patientsNuttingetal.(36)

214laboratoryresultsPlebaniandCarraro(8)

164laboratoryreportsStahletal.(37)

283laboratoryresultsHofgartnerandTait(9)

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SHOTandLaboratoryErrors

ReportyearNoofanalysedIBCTcasesNoand%ofcaseswithlaboratoryassiteofprimaryerror2000-011905529%2001-0234612035%200334815545%200443918041%200548517937%

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SHOTandLaboratoryErrors

TotalErrorsWrongSampleTranscriptionInterpretationComponentSelectionErrorsLabellingProceduralErrorsIncorrectProtocolTestingNotknownWrongBloodABOgroup2291021WrongBloodOthers1531911ABOmismatchedtransplant

11SpecialRequirementsNotMet7272InappropriateTransfusion44AntiDErrors23131315UnsafeTx2020OtherPretxTestingErrors22157

Totalerrors17913142851491122

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SHOTandLaboratoryErrors

TotalErrorsWrongSampleTranscriptionErrorsInterpretationErrorsComponentSelectionErrorsWrongBloodABOGroup229102WrongBlood

Others15319

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SHOTandLaboratoryErrors

TotalErrorsWrongSampleTranscriptionErrorsProceduralErrorsInProtocolTestingPre-TxTestingErrors22157Anti-DErrors

23131315

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SHOTandLaboratoryErrors

LaboratoryActivitySurvey2003:262/386(68%)returneddata

210(80%)providedworkloaddataRatioofworkloaddonein:corevnoncorehoursis80:20Ratiooflaberrorsmadein:corevnoncorehoursis60:40

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SHOTandLaboratoryErrors

72cases:Specialrequirementsnotmet30cases:Failuretoprovideirradiatedcomponents28cases:transfusionBMSstaffduringnormalworkinghours

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laboratoryerrors

Laboratoryproceduressuchasmultiplesamplescrossmatchedatthesametimeoracrossmatchbeingstartedbeforetheorderwasreceived.Staff-relatedfactorssuchasinsufficientorientationandtrainingorinsufficientstaffinglevels.

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laboratoryerrors

SpecialrequirementsnotmetUnitswronglylabelledinBloodBankDocumentationerrorsSampleerrors;bookingin,transpositionetcGroupingerrors

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laboratoryerrors(NEQAS)

HumanfailuretofollowproceduresenioritynoguaranteeofnomistakesUnabletoget2peopletocheckasnotalwaysavailablesamplemix-upinemergencyexercisenosubsequentcheckManualeditdidntfollowroutineprocedurewhichissafe

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laboratoryerrors(NEQAS)

SeverestaffingproblemspolicynotfollowedLackofresourcesnoenzymepanelLackofknowledgeaboutantibodyreactivityandguidelinesInadequatepolicyResulttranscriptionnotcheckedasCPAinspectioninprogress

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laboratoryerrors(NEQAS)

PolicyinplacebutBMSdidntfollowitMorein-housetrainingandcompetencyassessmentrequiredInsufficientstaffRelianceonagencystaffPoorskillmixwantallBMSstafftoparticipateinrecognisedBTtrainingscheme

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laboratoryerrors

Canwereduceoreliminatelaboratoryerrors?Blame,Fairblameornoblame?Brokenwindowtheory-wherefailuresaretolerated,failureswillaccumulate

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laboratoryerrors

Moreresource?Staff?Automation?MoreeducationMorecompetencychecksNewwaysofworkingSkillmixMoreerrorlogging

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Poka-yoke(|J)-pronouncedPOH-kahYOH-kehShigeoShingo()errorproofingPoka-yoke(|J)-pronouncedPOH-kahYOH-kehShigeoShingo()errorproofing

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