The detection and prevention of errors in laboratory medicine

Reduction of pre-analytical errors in the clinical laboratory at the University Hospital of Korea through quality improvement activities

BACKGROUND

The clinical laboratory is responsible for reporting accurate and expeditious results. However, the pre-analytical phase is directly related to the procedure of specimen collection and is mostly out of the direct control of the laboratory; further, most pre-analytical errors are related to human factors. Therefore, education and training programs for the phlebotomy teams are considered the most significant and necessary measures to reduce these errors.

METHODS

A cross-sectional study was conducted to investigate the types and frequencies of pre-analytical errors in the hospital laboratory. Pre-analytical errors were categorized into four main categories: rejected sample, error related to test ordering, misidentification, and others. Several activities were performed for quality improvement in order to reduce the rates of these errors. The data were analyzed by comparing the pre-intervention and post-intervention results along with the results of questionnaires to assess knowledge to investigate the effects of the activities.

RESULTS

The rates of pre-analytical errors decreased from 0.42% in the pre-intervention period to 0.32% in the post-intervention period. The rejected sample category accounted for the highest rates in the pre- and post-intervention periods. In the questionnaires, the overall average score after the intervention was 71.5, which was a significant increase from 46.0 in the pre-intervention period.

CONCLUSIONS

Each clinical laboratory has various types of pre-analytical errors due to the complexity of the healthcare environment. Therefore, targeted intervention including a quality improvement program and its continuous maintenance should be conducted to reduce pre-analytical errors and to improve patient safety.

Quantitative analysis of ATM phosphorylation in lymphocytes

Since many anticancer therapies target DNA and DNA damage response pathways, biomarkers of DNA damage endpoints may prove valuable in basic and clinical cancer research. Ataxia telangiectasia-mutated (ATM) kinase is the principal regulator of cellular responses to DNA double-strand breaks (DSBs). In humans, ATM autophosphorylation at serine 1981 (p-S1981) is an immediate molecular response to nascent DSBs and ionizing radiation (IR). Here we describe the analytical characteristics and fit-for-purpose validation of a quantitative dual-labeled immunoblot that simultaneously measures p-S1981-ATM and pan-ATM in human peripheral blood mononuclear cells (PBMCs) following ex vivo exposure to 2 Gy IR, facilitating the calculation of %p-ATM. To validate our assay, we isolated PBMCs from 41 volunteers. We report that the median basal level of p-S1981-ATM and pan-ATM was 2.4 and 49.5 ng/10⁷ PBMCs, respectively, resulting in %p-ATM of 4%. Following exposure of PBMCs to 2 Gy IR, p-S1981-ATM levels increased 12-fold to 29.8 ng/10⁷ PBMCs resulting in %p-ATM of 63%. Interestingly, we show that PBMCs from women have a 2.6-fold greater median p-S1981-ATM level following IR exposure than men (44.4 versus 16.9 ng/10⁷ cells; p < 0.01). This results in a significantly greater %p-ATM for women (68% versus 49%; p <  0.01). Our rigorous description of the analytical characteristics and reproducibility of phosphoprotein immunoblotting, along with our finding that the ATM DNA damage response is greater in women, has far reaching implications for biomedical researchers.

Sources and solutions for spurious test results in coagulation

In the coagulation laboratory, much emphasis has been placed on rapid and accurate testing; however, spurious results that are inaccurate and do not reflect the actual status of the patient can potentially lead to an incorrect diagnosis and altered intervention. Errors in coagulation results and interpretation can occur at any point of the process from obtaining the specimen to interpretation and use of the result by the clinician. The main sources of error include the patient's biological and preanalytical variation, analytical testing, and postanalytical use of the reported result(s). This article reviews various sources of error leading to spurious results, providing methods to recognize these aberrant results and presenting solutions for minimizing their occurrence.

The Importance of Specimen Reception and the Universal Challenges It Faces in Laboratory Flow: A Brief Overview

In this brief overview, I emphasize the importance of the specimen-reception department in the running and flow of a laboratory. Also, I outline the problems and the challenges it faces, which are almost universally applicable to all laboratories. To my knowledge, this topic has not been directly reported before in the literature.

The view of a general practitioner on immediate access for patients to their laboratory test results

This position paper presents the role of laboratory test results in traditional general practice and provides a recommendation for responsible sharing of results with patients for improved safety, efficiency and outcomes. This paper looks at the relationship between the laboratory, the general practitioner consultation, the patient, safety and general practice capacity. We suggest changes in the traditional practice of communicating laboratory test results whereby normal or abnormal results are made available to patients as soon as they become available. We also endorse the opinion that using online tools such as email or text messages could enhance the provision of rapid access to laboratory test results for patients.

Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees

BACKGROUND

Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.

OBJECTIVE

To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.

DESIGN

Cross-sectional survey.

PARTICIPANTS

General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals.

MAIN MEASURES

Methods used to track test results; satisfaction with these methods; personal encounters with results respondents "wish they had known about sooner."

KEY RESULTS

We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic "inbox") (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they "wish they had known about sooner" in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001).

CONCLUSIONS

Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.

Types and frequency of non-conformances in an IVF laboratory

STUDY QUESTION

How many non-conformances occur in an ART laboratory and how often do they occur?

SUMMARY ANSWER

The limited data to date demonstrate that IVF laboratories have a very low non-conformance rate compared with reported non-conformances in other medical laboratories, especially when one considers the high-complexity of procedures performed.

WHAT IS KNOWN ALREADY

ART involves a series of very complex patient and laboratory procedures. Although it is assumed that strict measures control ART laboratories, there is very little published data on non-conformances.

STUDY DESIGN, SIZE, DURATION

In accordance with the ISO 9001:2008 standard, Boston IVF has created an electronic database to record non-conformances in the IVF laboratory. We reviewed the non-conformances reported between March 2003 and December 2015. The non-conformances were categorized into four grades largely based upon their impact on the outcome or continuation of an IVF treatment cycle: None/Minimal (not measurably decreasing the likelihood of success), Moderate (a negative impact but not loss of a cycle), Significant (loss of a cycle or majority of gametes or embryos) and Major (infrequent errors that have an extreme impact on a patient or patients such as a confirmed pregnancy or birth involving misidentification of sperm, egg or embryo, or an extreme equipment or documentation failure that affects numerous patients). The category of problem or error associated with the Non-conformance Report was also noted.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Retrospective analysis of an electronic database registering non-conformances at a large IVF laboratory.

MAIN RESULTS AND THE ROLE OF CHANCE

During the study period, a total of 36 654 IVF treatment cycles (fresh and frozen embryo transfer cycles) were conducted which involved a total of 181 899 individual laboratory procedures encompassing egg retrievals, sperm preparations, inseminations, embryo transfers, etc. When combining both moderate and significant non-conformances, 99.96% of procedures and 99.77% of cycles proceeded with no non-conformances. No Major grade non-conformances were reported.

LIMITATIONS, REASONS FOR CAUTION

A comparison of non-conformances between IVF clinics is difficult because of different classifications.

WIDER IMPLICATIONS OF THE FINDINGS

Errors are inevitable and it is incumbent on all IVF centers to be honest and transparent, both within the organization and with patients when errors occur. Robust systems for identifying, documenting, analyzing and implementing improvements should be established and maintained.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The authors have no conflicts of interest.

System-related and cognitive errors in laboratory medicine

Current efforts focusing on better defining the prevalence of diagnostic errors, their causes and remediation strategies should address the role of laboratory testing and its contribution to high-quality care as well as a possible source of diagnostic errors. Data collected in the last few years highlight the vulnerability of extra-analytical phases of the testing cycle and the need for programs aiming to improve all steps of the process. Further studies have clarified the nature of laboratory-related errors, namely the evidence that both system-related and cognitive factors account for most errors in laboratory medicine. Technology developments are effective in decreasing the rates of system-related errors but organizational issues play a fundamental role in assuring a real improvement in quality and safety in laboratory processes. Educational interventions as well as technology-based interventions have been proposed to reduce the risk of cognitive errors. However, to reduce diagnostic errors and improve patient safety, clinical laboratories have to embark on a paradigmatic shift restoring the nature of laboratory services as an integral part of the diagnostic and therapy process.

An Optimized Workflow to Evaluate Estrogen Receptor Gene Mutations in Small Amounts of Cell-Free DNA

The detection of mutated genes in cell-free DNA (cfDNA) in plasma has emerged as an important minimally invasive way to obtain detailed information regarding tumor biology. Reliable determination of circulating tumor-derived DNA, often present at a low quantity amidst an excess of normal DNA in plasma, would be of added value for screening and monitoring of cancer patients and for hypothesis-generating studies in valuable retrospective cohorts. Our aim was to establish a workflow to simultaneously assess four hotspot estrogen receptor mutations (mESR1) in cfDNA isolated from only 200 μL of plasma by means of uniplex or multiplex pre-amplification combined with digital PCR. This workflow was then applied in metastatic breast cancer (MBC) patients receiving systemic therapies for MBC. In accordance with previous studies, estrogen receptor mutations were more frequently detected in endocrine-treated MBC patients at progressive disease [34.1% (15/44)] than before the start of endocrine therapy [3.9% (2/51); P = 0.001]. For a subset of samples, results were compared with analysis of these mutations by Oncomine-targeted next-generation sequencing, which, although requiring a higher cfDNA input, yielded concordant results. The data establish development and validation of a digital PCR workflow for the simultaneous detection of several tumor-derived mutations in minute amounts of cfDNA and show the potential of this workflow for use on archived volume-limited blood samples.

Harmonization in laboratory medicine: more than clinical chemistry?

The goal of harmonizing laboratory information is to contribute to quality in patient care, ultimately improving upon patient outcomes and safety. The main focus of harmonization and standardization initiatives has been on analytical processes within the laboratory walls, clinical chemistry tests in particular. However, two major evidences obtained in recent years show that harmonization should be promoted not only in the analytical phase but also in all steps of the testing process, encompassing the entire field of laboratory medicine, including innovative areas (e.g. “omics”) rather than just conventional clinical chemistry tests. A large body of evidence demonstrates the vulnerability of the extra-analytical phases of the testing cycle. Because only “good biological samples” can assure good analytical quality, a closer interconnection between the different phases of the cycle is needed. In order to provide reliable and accurate laboratory information, harmonization activities should cover all steps of the cycle from the “pre-pre-analytical” phase (right choice of test at right time for right patient) through the analytical steps (right results with right report) to the “post-post-analytical” steps (right and timely acknowledgment of laboratory information, right interpretation and utilization with any necessary advice as to what to do next with the information provided). In addition, modern clinical laboratories are performing a broad menu of hundreds of tests, covering both traditional and innovative subspecialties of the discipline. In addition, according to a centered viewpoint, harmonization initiatives should not be addressed exclusively to clinical chemistry tests but should also include all areas of laboratory medicine.

An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time

BACKGROUND

Diagnostic error is extremely common in the USA and likely around the world. A major reason for the diagnostic error is both the overutilization and the underutilization of laboratory tests. Using a panel of two to four experts in coagulation, test selection was reviewed in clinical context and in real time, and consensus determinations were made to derive conclusions about the extent of overutilization and underutilization.

METHODS

Two hundred cases of patients being evaluated for bleeding or thrombotic issues were presented at each daily meeting of the diagnostic management team, and a review of each case for appropriate utilization of tests was completed.

RESULTS

Two hundred randomly selected cases revealed 77.5% diagnostic errors (155 cases). Sixteen percent were associated with overutilization of laboratory tests, 44% were associated with underutilization, and 17.5% were associated with both. The annual cost burden estimated for overutilization alone in one institution of 450 beds was on the order of $20,000. The cost burden for the delay in diagnosis or the misdiagnosis in cases with underutilization is orders of magnitude greater ($200,000 or more), but it is impossible to determine the cost of a misdiagnosis in an individual case because it can produce many different clinical outcomes.

CONCLUSIONS

This was a rare opportunity for experts in a given field to review cases in real time and in clinical context and provide immediately a consensus answer about test utilization. The results of this study show errors in test selection in nearly 75% of the cases evaluated.

Racing for results: lessons learnt in improving the efficiency of HIV viral load and early infant diagnosis result delivery from laboratory to clinic

INTRODUCTION

In pursuit of the 90-90-90 goals, emphasis has been placed on accelerating centralized-laboratory HIV viral load testing of a population that is largely rural and decentralized. Successful outcome requires effective specimen transport, laboratory testing, and results delivery. This paper focuses on the methods currently employed for results delivery. New innovations in this area are yielding mixed results; we analyze different approaches and estimate the impact of each on achieving the third '90.' Areas covered: Strategies employing electronic or mobile health platforms, such as online portals, SMS, and SMS printers are showing potential to deliver results in significantly improved turnaround times but are not without challenges. Also, merely delivering a result to the clinic is not sufficient; results need to be actioned to ensure improved patient linkage and retention. Innovative solutions that not only support real-time reporting but monitor receipt of results and address infrastructure constraints faced by limited-resource settings are discussed. Expert commentary: There is tremendous opportunity to inform better patient care and directly contribute to '90-90-90' progress by developing digital systems for result delivery. Besides infrastructure and technical challenges, systems should address the entire cascade of care from initial diagnosis to monitoring treatment response.

Congruity in Quality Indicators and Laboratory Performance

Proficiency of laboratory services is the mainstay in clinical medicine in providing error free diagnostic results. The efficiency of the laboratory needs to be evaluated as per standard international criterion. The quality indicators of the different phases of total testing process are considered the fundamental measurable tool for evaluation of laboratory performance. In order to optimize the laboratory's proficiency and accreditate it as per international standard in our newly established lab, the study was conducted to evaluate the frequency of errors incurred by laboratory and nonlaboratory professionals during the whole testing process. Retrospective analysis was done for data received from April 2016 to Dec 2016 in our lab. Total number of samples received was 61,674, out of which 43200 samples could be analyzed for quality indicators. Total numbers of tests processed in these samples were 172,800. In the study samples, 26.5% errors were due to pre-analytical factors whereas 9.4% of errors were contributed by analytical phase and 18% by post-analytical phase. Inappropriateness of test requisition was observed to be the major attributing determinant for pre-analytical errors. Instrumentation efficiency in form of frequent breakdown (~7%), greatly affected the proficiency of analytical phase in our lab. 12% of post-analytical errors were ascribed by excessive turn-around-time. However, timeliness of critical value call out and reporting for STAT samples revealed high proficiency up to 97%. High error rates were observed in pre-pre- and pre-analytical phases that also accorded for high error frequency in post analytical phase. This emphasizes urgent need to formulate guidelines for processing all steps of total testing process and initiate strategic measures for reducing risk of errors and increasing patient safety.

Establishing a Dedicated Lung Cancer Biobank at the University Center Hospital of Nice (France). Why and How?

Lung cancer is the major cause of death from cancer in the world and its incidence is increasing in women. Despite the progress made in developing immunotherapies and therapies targeting genomic alterations, improvement in the survival rate of advanced stages or metastatic patients remains low. Thus, urgent development of effective therapeutic molecules is needed. The discovery of novel therapeutic targets and their validation requires high quality biological material and associated clinical data. With this aim, we established a biobank dedicated to lung cancers. We describe here our strategy and the indicators used and, through an overall assessment, present the strengths, weaknesses, opportunities and associated risks of this biobank.

Clinical laboratory: bigger is not always better

Laboratory services around the world are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on expectations to improve efficiency, increasing volumes and reducing the cost per test. However, the relationship between volume and costs is not linear and numerous variables influence the end cost per test. In particular, the relationship between volumes and costs does not span the entire platter of clinical laboratories: high costs are associated with low volumes up to a threshold of 1 million test per year. Over this threshold, there is no linear association between volumes and costs, as laboratory organization rather than test volume more significantly affects the final costs. Currently, data on laboratory errors and associated diagnostic errors and risk for patient harm emphasize the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. Process and outcome quality indicators are effective tools to measure and improve laboratory services, by stimulating a competition based on intra- and extra-analytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

Molecular Auditing: An Evaluation of Unsuspected Tissue Specimen Misidentification

CONTEXT.—

Specimen misidentification is the most significant error in laboratory medicine, potentially accounting for hundreds of millions of dollars in extra health care expenses and significant morbidity in patient populations in the United States alone. New technology allows the unequivocal documentation of specimen misidentification or contamination; however, the value of this technology currently depends on suspicion of the specimen integrity by a pathologist or other health care worker.

OBJECTIVE.—

To test the hypothesis that there is a detectable incidence of unsuspected tissue specimen misidentification among cases submitted for routine surgical pathology examination.

DESIGN.—

To test this hypothesis, we selected specimen pairs that were obtained at different times and/or different hospitals from the same patient, and compared their genotypes using standardized microsatellite markers used commonly for forensic human DNA comparison in order to identify unsuspected mismatches between the specimen pairs as a trial of "molecular auditing." We preferentially selected gastrointestinal, prostate, and skin biopsies because we estimated that these types of specimens had the greatest potential for misidentification.

RESULTS.—

Of 972 specimen pairs, 1 showed an unexpected discordant genotype profile, indicating that 1 of the 2 specimens was misidentified. To date, we are unable to identify the etiology of the discordance.

CONCLUSIONS.—

These results demonstrate that, indeed, there is a low level of unsuspected tissue specimen misidentification, even in an environment with careful adherence to stringent quality assurance practices. This study demonstrates that molecular auditing of random, routine biopsy specimens can identify occult misidentified specimens, and may function as a useful quality indicator.

Test results management and distributed cognition in electronic health record-enabled primary care

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

ctDNA and CTCs in Liquid Biopsy - Current Status and Where We Need to Progress

We discuss the current status of liquid biopsy and its advantages and challenges with a focus on pre-analytical sample handling, technologies and workflows. The potential of circulating tumor cells and circulating tumor DNA is pointed out and an overview of corresponding technologies is given.

Integrating Research Techniques to Improve Quality and Safety in the Preanalytical Phase

Background

Reducing errors in the preanalytical phase is difficult, which suggests the issue may be multidimensional. As such, qualitative research may be truly innovative in this context.

Method

We carried out a descriptive study using a qualitative method incorporating 4 focus groups. Data analysis followed the principles of Grounded Theory.

Results

We queried in each of the 4 focus groups collectively to identify weaknesses in the system. Those weaknesses that were most cited were logistics, coupled with uneven compliance with regulations.

Conclusion

All 4 focus groups mapped out directives for future work, so that regulatory aspects, process management, communication and resources could be identified as key areas where error reduction is critical.

Critical appraisal of the Vienna consensus: performance indicators for assisted reproductive technology laboratories

The Vienna consensus, based on the recommendations of an expert panel, has identified 19 performance indicators for assisted reproductive technology (ART) laboratories. Two levels of reference values are established for these performance indicators: competence and benchmark. For over 10 years, the Spanish embryology association (ASEBIR) has participated in the definition and design of ART performance indicators, seeking to establish specific guidelines for ART laboratories to enhance quality, safety and patient welfare. Four years ago, ASEBIR took part in an initiative by AENOR, the Spanish Association for Standardization and Certification, to develop a national standard in this field (UNE 17900:2013 System of quality management for assisted reproduction laboratories), extending the former requirements, based on ISO 9001, to include performance indicators. Considering the experience acquired, we discuss various aspects of the Vienna consensus and consider certain discrepancies in performance indicators between the consensus and UNE 179007:2013, and analyse the definitions, methodology and reference values used.

Laboratory testing in primary care: A systematic review of health IT impacts

INTRODUCTION

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated.

OBJECTIVES

To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care.

METHODS

We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur.

RESULTS

Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory.

DISCUSSION

The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions.

CONCLUSIONS

By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing.

Laboratory error reporting rates can change significantly with year-over-year examination

BACKGROUND

Incident reporting systems are useful tools to raise awareness of patient safety issues associated with healthcare error, including errors associated with the medical laboratory.

METHODS

Previously, we presented the analysis of data compiled by the British Columbia Patient Safety & Learning System over a 3-year period. A second comparable set was collected and analyzed to determine if reported error rates would tend to remain stable or change.

RESULTS

Compared to the original set, the second set presented changes that were both materially and statistically significant. Overall, the total number of reports increased by 297% with substantial changes between the pre-examination, examination and post-examination phases (χ2: 993.925, DF=20; p<0.00001). While the rate of change for pre-examination (clerical and collection) errors were not significantly different than the total year results, the rate of change for reporting examination errors rose by 998%. While the exact reason for dramatic change is not clear, possible explanations are provided.

CONCLUSIONS

Longitudinal error rate tracking is a useful approach to monitor for laboratory quality improvement.

Elevated zinc concentrations in a 5 months old infant: A case report

Pre-analytical errors account for the majority of laboratory-associated errors. In a 5 months old infant hospitalised with lung dysfunction due to prematurity, a routine measurement of zinc revealed an unexpected elevated concentration of 20.2 µmol/L (reference interval 10.0 - 19.0 µmol/L) compared to 11.6 µmol/L five days earlier. Zinc measurement was repeated two days later and had further increased to 42.4 µmol/L. Of note, there were no clinical signs of the increased zinc concentrations. Performance data for the zinc analysis (performed by inductively coupled plasma mass spectrometry) was found satisfactory. A thorough review of the patient´s medication and nutrition supplements revealed no relevant zinc content. The blood was obtained through capillary blood sampling, and anything at the skin puncture site containing zinc could therefore potentially contribute to the elevated zinc results. It was investigated if any ointment containing zinc had been applied at the puncture site, which revealed that the mother had applied vitamin E ointment containing zinc-oxide at the infant’s heel. A capillary sample obtained from the opposite heel, where no vitamin E ointment had been applied, revealed a zinc concentration of 14.3 µmol/L. In conclusion, pre-analytical contamination with ointments must be considered in case of unexpected measurements from capillary blood.

Engineering of a miniaturized, robotic clinical laboratory

The ability to perform laboratory testing near the patient and with smaller blood volumes would benefit patients and physicians alike. We describe our design of a miniaturized clinical laboratory system with three components: a hardware platform (ie, the miniLab) that performs preanalytical and analytical processing steps using miniaturized sample manipulation and detection modules, an assay-configurable cartridge that provides consumable materials and assay reagents, and a server that communicates bidirectionally with the miniLab to manage assay-specific protocols and analyze, store, and report results (i.e., the virtual analyzer). The miniLab can detect analytes in blood using multiple methods, including molecular diagnostics, immunoassays, clinical chemistry, and hematology. Analytical performance results show that our qualitative Zika virus assay has a limit of detection of 55 genomic copies/ml. For our anti-herpes simplex virus type 2 immunoglobulin G, lipid panel, and lymphocyte subset panel assays, the miniLab has low imprecision, and method comparison results agree well with those from the United States Food and Drug Administration-cleared devices. With its small footprint and versatility, the miniLab has the potential to provide testing of a range of analytes in decentralized locations.

External quality assessment of medical laboratories in Croatia: preliminary evaluation of post-analytical laboratory testing

Introduction

Proper standardization of laboratory testing requires assessment of performance after the tests are performed, known as the post-analytical phase. A nationwide external quality assessment (EQA) scheme implemented in Croatia in 2014 includes a questionnaire on post-analytical practices, and the present study examined laboratory responses in order to identify current post-analytical phase practices and identify areas for improvement.

Materials and methods

In four EQA exercises between September 2014 and December 2015, 145-174 medical laboratories across Croatia were surveyed using the Module 11 questionnaire on the post-analytical phase of testing. Based on their responses, the laboratories were evaluated on four quality indicators: turnaround time (TAT), critical values, interpretative comments and procedures in the event of abnormal results. Results were presented as absolute numbers and percentages.

Results

Just over half of laboratories (56.3%) monitored TAT. Laboratories varied substantially in how they dealt with critical values. Most laboratories (65-97%) issued interpretative comments with test results. One third of medical laboratories (30.6-33.3%) issued abnormal test results without confirming them in additional testing.

Conclusion

Our results suggest that the nationwide post-analytical EQA scheme launched in 2014 in Croatia has yet to be implemented to the full. To close the gaps between existing recommendations and laboratory practice, laboratory professionals should focus on ensuring that TAT is monitored and lists of critical values are established within laboratories. Professional bodies/institutions should focus on clarify and harmonized rules to standardized practices and applied for adding interpretative comments to laboratory test results and for dealing with abnormal test results.

External Quality Assessment beyond the analytical phase: an Australian perspective

External Quality Assessment (EQA) is the verification, on a recurring basis, that laboratory results conform to expectations for the quality required for patient care. It is now widely recognised that both the pre- and post-laboratory phase of testing, termed the diagnostic phases, are a significant source of laboratory errors. These errors have a direct impact on both the effectiveness of the laboratory and patient safety. Despite this, Australian laboratories tend to be focussed on very narrow concepts of EQA, primarily surrounding test accuracy, with little in the way of EQA programs for the diagnostic phases. There is a wide range of possibilities for the development of EQA for the diagnostic phases in Australia, such as the utilisation of scenarios and health informatics. Such programs can also be supported through advances in health information and communications technology, including electronic test ordering and clinical decision support systems. While the development of such programs will require consultation and support from the referring doctors, and their format will need careful construction to ensure that the data collected is de-identified and provides education as well as useful and informative data, we believe that there is high value in the development of such programs. Therefore, it is our opinion that all pathology laboratories should strive to be involved in an EQA program in the diagnostic phases to both monitor the diagnostic process and to identify, learn from and reduce errors and near misses in these phases in a timely fashion.

Generating method-specific Reference Ranges - A harmonious outcome?

OBJECTIVES

When laboratory Reference Ranges (RR) do not reflect analytical methodology, result interpretation can cause misclassification of patients and inappropriate management. This can be mitigated by determining and implementing method-specific RRs, which was the main objective of this study.

DESIGN AND METHODS

Serum was obtained from healthy volunteers (Male + Female, n > 120) attending hospital health-check sessions during June and July 2011. Pseudo-anonymised aliquots were stored (at - 70 °C) prior t° analysis on Abbott ARCHITECT c16000 chemistry and i2000SR immunoassay analysers. Data were stratified by gender where appropriate. Outliers were excluded statistically (Tukey method) to generate non-parametric RRs (2.5th + 97.5th percentiles). RRs were compared to those quoted by Abbott and UK Pathology Harmony (PH) where possible. For 7 selected tests, RRs were verified using a data mining approach.

RESULTS

For chemistry tests (n = 23), Upper or Lower Reference Limits (LRL or URL) were > 20% different from Abbott ranges in 25% of tests (11% from PH ranges) but in 38% for immunoassay tests (n = 13). RRs (mmol/L) for sodium (138-144), potassium (3.8-4.9) and chloride (102-110) were considerably narrower than PH ranges (133-146, 3.5-5.0 and 95-108, respectively). The gender difference for ferritin (M: 29-441, F: 8-193 ng/mL) was more pronounced than reported by Abbott (M: 22-275, F: 5-204 ng/mL). Verification studies showed good agreement for chemistry tests (mean [SD] difference = 0.4% [1.2%]) but less so for immunoassay tests (27% [29%]), particularly for TSH (LRL).

CONCLUSION

Where resource permits, we advocate using method-specific RRs in preference to other sources, particularly where method bias and lack of standardisation limits RR transferability and harmonisation.

Comparison of pneumatic tube system with manual transport for routine chemistry, hematology, coagulation and blood gas tests

BACKGROUND

The pneumatic tube system (PTS) is commonly used in modern clinical laboratories to provide quick specimen delivery. However, its impact on sample integrity and laboratory testing results are still debatable. In addition, each PTS installation and configuration is unique to its institution. We sought to validate our Swisslog PTS by comparing routine chemistry, hematology, coagulation and blood gas test results and sample integrity indices between duplicate samples transported either manually or by PTS.

METHODS

Duplicate samples were delivered to the core laboratory manually by human courier or via the Swisslog PTS. Head-to-head comparisons of 48 routine chemistry, hematology, coagulation and blood gas laboratory tests, and three sample integrity indices were conducted on 41 healthy volunteers and 61 adult patients.

RESULTS

The PTS showed no impact on sample hemolysis, lipemia, or icterus indices (all p<0.05). Although alkaline phosphatase, total bilirubin and hemoglobin reached statistical significance (p=0.009, 0.027 and 0.012, respectively), all had very low average bias which ranged from 0.01% to 2%. Potassium, total hemoglobin and percent deoxyhemoglobin were statistically significant for the neonatal capillary tube study (p=0.011, 0.033 and 0.041, respectively) but no biases greater than ±4% were identified for these parameters. All observed differences of these 48 laboratory tests were not clinically significant.

CONCLUSIONS

The modern PTS investigated in this study is acceptable for reliable sample delivery for routine chemistry, hematology, coagulation and blood gas (in syringe and capillary tube) laboratory tests.

Prevalence of Tritrichomonas foetus in tennessee bulls

The prevalence of bovine trichomonosis (BT) in TN bulls was estimated through both active screening of bulls and review of previous laboratory records. During the active bull screening, preputial smegma specimens were collected from 458 TN beef bulls at 2 cattle slaughterhouses and 2 stockyards, which serve most beef bulls in TN, between March 2014 and June 2015. Each specimen was cultured for Tritrichomonas foetus (T. foetus) as well as evaluated microscopically every other day for seven days for any protozoa resembling T. foetus. An aliquot of the culture media from each specimen was used for DNA extraction and subsequent qPCR testing. Two specimens were considered suspect on microscopic evaluation, but all specimens were negative for T. foetus on qPCR. This suggests that the 2 specimens were most likely contaminated by fecal trichomonads. Retrospectively, 1979 T. foetus test records from 2 major TN diagnostic laboratories were reviewed between October 2013 and September 2016. True prevalence of BT in TN beef bulls was estimated at <0.01% from the laboratory records, although the county prevalence differed in 2 TN counties (Marshal: 0.09% and Bedford: 0.5%). Overall, the prevalence of BT in TN is low, and the current screening efforts to help control BT disease in TN are acceptable. Future efforts should focus on educating cattle stakeholders on the importance of optimal specimen collection and handling as well as routine testing for BT before cattle movement. In addition, cattle producers should be reminded of leading risk factors associated with BT in cattle.

Pre-analytical Errors at the Chemical Pathology Laboratory of a Teaching Hospital

INTRODUCTION

The Chemical Pathology Laboratory at the University Hospital of the West Indies (UHWI) processes specimens received from inpatients, the outpatient department and other medical facilities in Jamaica. Specific rejection criteria are used to determine samples unsuitable for analysis. It has been noted that despite efforts to reduce the number of unacceptable samples received in the laboratory, the problem persists.

AIM

The study seeks to provide empirical evidence of the inadequacies from which improvements can be formulated.

MATERIALS AND METHODS

Errors recorded in the rejection log in the Chemical Pathology laboratory at the University Hospital of the West Indies for the period were assessed. The types and frequency of errors were determined manually. The yearly rejection ratios over a four-year period were evaluated.

RESULTS

The most common causes for rejection were unlabelled samples (37%), incorrectly labelled specimens (23%), samples submitted in an inappropriate tube (14%) and incomplete or inaccurately completed requisition forms (14%). The rejection ratio for 2015-2016 was 2.1%.

CONCLUSION

The laboratory must initiate programmes directed at improving the preanalytical process in order to ensure patient safety.

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

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.

In control? IQC consensus and statutory regulation

Purpose - Internal quality control (IQC) represents an essential risk management tool within the total testing pathway (TTP) that contributes to the overall objective of assuring the quality of results produced in medical laboratories. Controlling analytical phase quality alone requires significant expertise and input by scientifically trained staff. This effort has escalated exponentially following the publication of the International Organisation for Standardisation (ISO)15189:2012 requirements for quality and competence in medical laboratories. The reported inconsistency and diversity to IQC approaches in diagnostic laboratories is definitive evidence that international guidance in IQC programme design and implementation is long overdue. The paper aims to discuss these issues. Design/methodology/approach - Herein, the authors define, describe and critically examine the essential elements four stages of an IQC programme and suggest a template to inform both design and ease of implementation. For practical application, the authors have stratified the proposed methodology into four stages: staff education and training; IQC material; IQC targets; and IQC procedure, and provide recommendations that meet ISO15189:2012 requirements. Findings - These recommendations are informed by the published literature together with the collective experience working in clinical biochemistry and diagnostic endocrinology laboratories. The authors note that the laboratory staff's effort on IQC is a continuous process, driven by changes within each IQC stage, in response to risk analysis, maximising economic value or through professional leadership and central to IQC programme implementation and delivery. Practical implications - The authors offer a template that laboratories can use to inform the design and implementation of their IQC programme. Originality/value - The proposed IQC programme is user friendly, flexible and pragmatic with the potential to harmonise practice. The authors have provided a template to potentially harmonise IQC practice nationally. Given the central and critical role that IQC practice plays in ensuring the quality of patient results' importance, the authors contend that the time has come for international consensus and statutory regulation regarding the minimally acceptable criteria for its implementation, monitoring and review.

Laboratory services: regaining and maintaining control

Purpose - After implementing an internal quality control (IQC) programme, the purpose of this paper is to maintain the requisite analytical performance for clinical laboratory staff, thereby safeguarding patient test results for their intended medical purpose. Design/methodology/approach - The authors address how quality can be maintained and if lost, how it can be regained. The methodology is based on the experience working in clinical laboratory diagnostics and is in accord with both international accreditation requirements and laboratory best practice guidelines. Findings - Monitoring test performance usually involves both prospective and retrospective IQC data analysis. The authors present a number of different approaches together with software tools currently available and emerging, that permit performance monitoring at the level of the individual analyser, across analysers and laboratories (networks). The authors make recommendations on the appropriate response to IQC rule warnings, failures and metrics that indicate analytical control loss, that either precludes further analysis, or signifies deteriorating performance and eventual unsuitability. The authors provide guidance on systematic troubleshooting, to identify undesirable performance and consider risk assessment preventive measures and continuous quality improvement initiatives; e.g., material acceptance procedures, as tools to help regain and maintain analytical control and minimise potential for patient harm. Practical implications - The authors provide a template for use by laboratory scientific personnel that ensures the optimal monitoring of analytical test performance and response when it changes undesirably. Originality/value - The proposed template has been designed to meet the International Organisation for Standardisation for medical laboratories ISO15189:2012 requirements and therefore includes the use of External Quality Assessment and patient results data, as an adjunct to IQC data.

Missed diagnostic opportunities within South Africa's early infant diagnosis program, 2010-2015

BACKGROUND

Samples submitted for HIV PCR testing that fail to yield a positive or negative result represent missed diagnostic opportunities. We describe HIV PCR test rejections and indeterminate results, and the associated delay in diagnosis, within South Africa's early infant diagnosis (EID) program from 2010 to 2015.

METHODS

HIV PCR test data from January 2010 to December 2015 were extracted from the National Health Laboratory Service Corporate Data Warehouse, a central data repository of all registered test-sets within the public health sector in South Africa, by laboratory number, result, date, facility, and testing laboratory. Samples that failed to yield either a positive or negative result were categorized according to the rejection code on the laboratory information system, and descriptive analysis performed using Microsoft Excel. Delay in diagnosis was calculated for patients who had a missed diagnostic opportunity registered between January 2013 and December 2015 by means of a patient linking-algorithm employing demographic details.

RESULTS

Between 2010 and 2015, 2 178 582 samples were registered for HIV PCR testing of which 6.2% (n = 134 339) failed to yield either a positive or negative result, decreasing proportionally from 7.0% (n = 20 556) in 2010 to 4.4% (n = 21 388) in 2015 (p<0.001). Amongst 76 972 coded missed diagnostic opportunities, 49 585 (64.4%) were a result of pre-analytical error and 27 387 (35.6%) analytical error. Amongst 49 694 patients searched for follow-up results, 16 895 (34.0%) had at least one subsequent HIV PCR test registered after a median of 29 days (IQR: 13-57), of which 8.4% tested positive compared with 3.6% of all samples submitted for the same period.

CONCLUSIONS

Routine laboratory data provides the opportunity for near real-time surveillance and quality improvement within the EID program. Delay in diagnosis and wastage of resources associated with missed diagnostic opportunities must be addressed and infants actively followed-up as South Africa works towards elimination of mother-to-child transmission.

Evaluation of Preanalytical Quality Indicators by Six Sigma and Pareto`s Principle

Preanalytical steps are the major sources of error in clinical laboratory. The analytical errors can be corrected by quality control procedures but there is a need for stringent quality checks in preanalytical area as these processes are done outside the laboratory. Sigma value depicts the performance of laboratory and its quality measures. Hence in the present study six sigma and Pareto principle was applied to preanalytical quality indicators to evaluate the clinical biochemistry laboratory performance. This observational study was carried out for a period of 1 year from November 2015-2016. A total of 1,44,208 samples and 54,265 test requisition forms were screened for preanalytical errors like missing patient information, sample collection details in forms and hemolysed, lipemic, inappropriate, insufficient samples and total number of errors were calculated and converted into defects per million and sigma scale. Pareto`s chart was drawn using total number of errors and cumulative percentage. In 75% test requisition forms diagnosis was not mentioned and sigma value of 0.9 was obtained and for other errors like sample receiving time, stat and type of sample sigma values were 2.9, 2.6, and 2.8 respectively. For insufficient sample and improper ratio of blood to anticoagulant sigma value was 4.3. Pareto`s chart depicts out of 80% of errors in requisition forms, 20% is contributed by missing information like diagnosis. The development of quality indicators, application of six sigma and Pareto`s principle are quality measures by which not only preanalytical, the total testing process can be improved.

Towards a new paradigm in laboratory medicine: the five rights

A body of evidence collected in the last few decades demonstrates that the pre- and post-analytical phases of the testing cycle are more error-prone than the analytical phase. However, the paradigm of errors and quality in laboratory medicine has been questioned, analytical mistakes continuing to be a major cause of adverse clinical outcomes and patient harm. Although the brain-to-brain concept is widely recognized in the community of laboratory professionals, there is lack of clarity concerning the inter-relationship between the different phases of the cycle, interdependence between the pre-analytical phase and analytical quality, and the effect of the post-analytical steps on the quality of ultimate laboratory information. Analytical quality remains the "core business" of clinical laboratories, but laboratory professionals and clinicians alike should never lose sight of the fact that pre-analytical variables are often responsible for erroneous test results and that quality biospecimens are pre-requisites for a reliable analytical phase. In addition, the pressure for expert advice on test selection and interpretation of results has increased hand in hand with the ever-increasing complexity of tests and diagnostic fields. Finally, the data on diagnostic errors and inappropriate clinical decisions made due to delay or misinterpretation of laboratory data underscore the current need for greater collaboration at the clinical-laboratory interface.

Assuring the quality of interpretative comments in clinical chemistry

The provision of interpretative advice on laboratory results is a post-analytic activity and an integral part of clinical laboratory services. It is valued by healthcare workers and has the potential to prevent or reduce errors and improve patient outcomes. It is important to ensure that interpretative comments provided by laboratory personnel are of high quality: comments should be patient-focused and answer the implicit or explicit question raised by the requesting clinician. Comment providers need to be adequately trained and qualified and be able to demonstrate their proficiency to provide advice on laboratory reports. External quality assessment (EQA) schemes can play a part in assessing and demonstrating the competence of such laboratory staff and have an important role in their education and continuing professional development. A standard structure is proposed for EQA schemes for interpretative comments in clinical chemistry, which addresses the scope and method of assessment including nomenclature and marking scales. There is a need for evidence that participation in an EQA program for interpretative commenting facilitates improved quality of comments. It is proposed that standardizing goals and methods of assessment as well as nomenclature and marking scales may help accumulate evidence to demonstrate the impact of participation in EQA for interpretative commenting on patient outcome.

Preliminary probe of quality indicators and quality specification in total testing process in 5753 laboratories in China

BACKGROUND

The aim of the study was to promote the establishment and implementation of quality indicators (QIs) in clinical laboratories, catch up with the state of art, and provide preliminary quality specifications for established QIs.

METHODS

Clinical laboratories from different provinces in China were included in this QIs survey in 2015. All participants were asked to collect data related to QIs and complete QIs questionnaires. Defect percentages and sigma values were calculated for each QI. The 25th percentile, median, and the 75th percentile of defect percentages and TATs were calculated as optimum, desirable and minimum quality specifications. While 25th, median, and 75th of sigma values were calculated as minimum, desirable and optimum quality specifications, respectively.

RESULTS

Five thousand seven hundred and fifty-three clinical laboratories from 28 provinces in China participated in this survey. Median defect percentages of pre-examination QIs varied largely from 0.01% (incorrect sample container) to 0.57% (blood culture contamination) with sigma values varied from 4.0σ to 5.1σ. Median defect percentages of examination phase QIs were all really high. The most common problem in examination phase was test uncovered by inter-laboratory comparison (86.67%). Defect percentages of critical values notification and timely critical values notification were all 0.00% (6.0σ). While the median of defect percentages of incorrect laboratory reports was only 0.01% (5.4σ).

CONCLUSIONS

Improvements are needed in all phases of total testing process (TTP) in laboratories in China, especially in examination phase. More attention should be paid when microbiology specimens are collected and results are reported. Quality specifications can provide directions for laboratories to make effort for.