Laboratory network of excellence: enhancing patient safety and service effectiveness

Sigma metric analysis of quality indicators across the testing process as an effective tool for the evaluation of laboratory performance

Background

Laboratories across the world are successfully using quality indicators (QIs) to monitor their performance. We aimed to analyze the effectiveness of using the peer group comparison and statistical tools such as sigma metrics for periodic evaluation of QIs and identify potential errors in the preanalytical, analytical, and postanalytical phases.

Methods

We evaluated the monthly QIs for 1 year. A total of 11 QIs were evaluated across the three phases of the total testing process, using percentage variance, and sigma metric analysis.

Results

Our study observed that based on sigma metric analysis, the performance was good for all the QIs except for the number of samples with the inappropriate specimen hemolyzed samples, clotted samples, and turnaround time (Sigma value < 3). The percentage variance of QIs in all the phases was plotted in a Pareto chart, which helped us in identifying turnaround time and internal quality control performance are the key areas that contribute to almost 80% of the errors among all the QIs.

Conclusion

Laboratory performance evaluation using QIs and sigma metric analysis helped us in identifying and prioritizing the corrective actions in the key areas of the total testing process.

Laboratory interpretative comments and guidance: clinical and operative outcomes on moderate to severe hyponatraemia patient management

AIMS

Hyponatraemia is the most common body fluid disorders but often goes unnoticed. Our laboratory incorporated a standardised procedure to help clinicians detect moderate/severe hyponatraemia. The study aims were to evaluate the outcomes on patient care and clinicians' satisfaction.

METHODS

The study, observational and retrospective, included 1839 cases, adult and paediatric patients, with sodium concentration <130 mmol/L. The procedure consisted of interpretative comments in the emergency and core laboratories report and the point-of-care testing blood gas network report. We evaluated hyponatraemia length in two equal periods: before and after the implementation. We conducted a survey addressed to the staff of the clinical settings involved to know their satisfaction.

RESULTS

The median hyponatraemia length decreased significantly from 4.95 hours (2.08-16.57) in the first period to 2.17 hours (1.06-5.39) in the second period. The lack of hyponatraemia patients follow-up was significantly less after the procedure implementation. The survey was answered by 92 (60 senior specialists and 32 residents) out of 110 clinicians surveyed. Ninety of them (98%) answered positively.

CONCLUSIONS

We have demonstrated the reduction in the time for diagnosing and management by physicians, the higher uniformity in the time required to solve hyponatraemia episodes following our laboratory procedure and the clinicians' satisfaction.

Clinical laboratory services for primary healthcare centers in urban cities: a pilot ACO model of ten primary healthcare centers

Background

Primary healthcare centers (PHC) ensure that patients receive comprehensive care from promotion and prevention to treatment, rehabilitation, and palliative care in a familiar environment. It is designed to provide first-contact, continuous, comprehensive, and coordinated patient care that will help achieve equity in the specialty healthcare system. The healthcare in Saudi Arabia is undergoing transformation to Accountable Care Organizations (ACO) model. In order for the Kingdom of Saudi Arabia (KSA) to achieve its transformational goals in healthcare, the improvement of PHCs’ quality and utilization is crucial. An integral part of this service is the laboratory services.

Methods

This paper presents a pilot model for the laboratory services of PHC's in urban cities. The method was based on the FOCUS-PDCA quality improvement method focusing on the pre-analytical phase of the laboratory testing as well as the Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) gap analysis and readiness within the ten piloted primary healthcare centers.

Results

The Gap analysis, revealed in-consistency in the practice, lead to lower the quality of the service, which was seen in the low performance of the chosen key performance indicators (KPI's) (high rejection rates, lower turn-around times (TAT) for test results) and also in the competency of the staff. Following executing the interventions, and by using some of the ACO Laboratory strategies; the KPI rates were improved, and our results exceeded the targets that we have set to reach during the first year. Also introducing the electronic connectivity improved the TAT KPI and made many of the processes leaner.

Conclusions

Our results revealed that the centralization of PHC's laboratory service to an accredited reference laboratory and implementing the national accreditation standards improved the testing process and lowered the cost, for the mass majority of the routine laboratory testing. Moreover, the model shed the light on how crucial the pre-analytical phase for laboratory quality improvement process, its effect on cost reduction, and the importance of staff competency and utilization.

Something's Lost and Something's Gained: Seeing Reference Laboratory Quality from Both Sides, Now

Growing regulatory burdens, payment model changes, and increased complexity in laboratory medicine have contributed to an increased reliance on reference laboratories. Although reference laboratories often offer rapid, low cost, high quality testing, outsourcing laboratory tests can create quality and patient safety vulnerabilities particularly in the pre-analytic and post-analytic phases of the test cycle. Disconnects in governance, policy, and information technology between the reference laboratory and the referring provider conspire to increase risk. Laboratory leaders seeking to reduce risk and improve quality must ensure clear and collaborative oversight, monitor meaningful quality metrics, and integrate feedback from ordering providers.

Continuing Patient Care during Electronic Health Record Downtime

INTRODUCTION

Electronic health record (EHR) downtime is any period during which the EHR system is fully or partially unavailable. These periods are operationally disruptive and pose risks to patients. EHR downtime has not sufficiently been studied in the literature, and most hospitals are not adequately prepared.

OBJECTIVE

The objective of this study was to assess the operational implications of downtime with a focus on the clinical laboratory, and to derive recommendations for improved downtime contingency planning.

METHODS

A hybrid qualitative-quantitative study based on historic performance data and semistructured interviews was performed at two mid-Atlantic hospitals. In the quantitative analysis, paper records from downtime events were analyzed and compared with normal operations. To enrich this quantitative analysis, interviews were conducted with 17 hospital employees, who had experienced several downtime events, including a hospital-wide EHR shutdown.

RESULTS

During downtime, laboratory testing results were delayed by an average of 62% compared with normal operation. However, the archival data were incomplete due to inconsistencies in the downtime paper records. The qualitative interview data confirmed that delays in laboratory result reporting are significant, and further uncovered that the delays are often due to improper procedural execution, and incomplete or incorrect documentation. Interviewees provided a variety of perspectives on the operational implications of downtime, and how to best address them. Based on these insights, recommendations for improved downtime contingency planning were derived, which provide a foundation to enhance Safety Assurance Factors for EHR Resilience guides.

CONCLUSION

This study documents the extent to which downtime events are disruptive to hospital operations. It further highlights the challenge of quantitatively assessing the implication of downtimes events, due to a lack of otherwise EHR-recorded data. Organizations that seek to improve and evaluate their downtime contingency plans need to find more effective methods to collect data during these times.

Clinical chemistry laboratory errors at St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia

Objective

This study was aimed to determine the magnitude of errors in clinical chemistry laboratory tests at different phases of the assay of clinical chemistry laboratory unit.

Results

From the total 1633 clinical chemistry laboratory tests done, overall, 541 (33.1%) errors occurred which accounts that 392 (72.3%), 45 (8.3%), and 104 (19.2%) were pre analytical, analytical and post analytical phases of errors, respectively. Incomplete clinical data of patient was observed on 1185 (72.6%) of CLL tests. Name, gender, and age of patients were missed on 8 (0.5%), 190 (11.6%), and 257 (15.7%) forms of the requests, respectively. The physician’s name existed only on 248 (15.2%) and signature on 1137 (69.6%) of the request forms. An essential patient data were incomplete, which needs emphasis on awareness creation. Such practice improves laboratory data interpretation and thereby prevent misdiagnose and mistreatment of patients.

The Effects of Education and Training Given to Phlebotomists for Reducing Preanalytical Errors

BACKGROUND

The most common sources of error in the preanalytical phase are considered to be at the stage of patient preparation and sample collection. In order to reduce the preanalytical errors, we aimed to determine the level of phlebotomists knowledge about the preanalytic phase before and after planned trainings in the study.

METHODS

Training about preanalytical processes was given to the 454 health professionals and the majority of them were employed as nurse. Questionnaires before and after training were conducted. In order to assess the effect of the training into the process, preanalytical error rates were calculated before and after training.

RESULTS

The total correct answer rates of vocational school of health diplomaed were statistically lower than the total correct answer rates of other. It was observed significantly increase in the rate of correct answers to questionnaire and significantly decrease in preanalytical error rates after training.

CONCLUSIONS

The results of the survey showed that the attitudes of the phlebotomists were diverse in the preanalytical processes according to the levels of education and their practices. By providing training to all staff on a regular basis, their information about preanalytical phase could be updated and hence, it may possible to significantly reduce the preanalytical errors in health practice and nursing science.

A Map for Clinical Laboratories Management Indicators in the Intelligent Dashboard

INTRODUCTION

management challenges of clinical laboratories are more complicated for educational hospital clinical laboratories. Managers can use tools of business intelligence (BI), such as information dashboards that provide the possibility of intelligent decision-making and problem solving about increasing income, reducing spending, utilization management and even improving quality. Critical phase of dashboard design is setting indicators and modeling causal relations between them. The paper describes the process of creating a map for laboratory dashboard.

METHODS

the study is one part of an action research that begins from 2012 by innovation initiative for implementing laboratory intelligent dashboard. Laboratories management problems were determined in educational hospitals by the brainstorming sessions. Then, with regard to the problems key performance indicators (KPIs) specified.

RESULTS

the map of indicators designed in form of three layered. They have a causal relationship so that issues measured in the subsequent layers affect issues measured in the prime layers.

CONCLUSION

the proposed indicator map can be the base of performance monitoring. However, these indicators can be modified to improve during iterations of dashboard designing process.

Pre-analytical errors management in the clinical laboratory: a five-year study

Introduction:

This study describes quality indicators for the pre-analytical process, grouping errors according to patient risk as critical or major, and assesses their evaluation over a five-year period.

Materials and methods:

A descriptive study was made of the temporal evolution of quality indicators, with a study population of 751,441 analytical requests made during the period 2007–2011. The Runs Test for randomness was calculated to assess changes in the trend of the series, and the degree of control over the process was estimated by the Six Sigma scale.

Results:

The overall rate of critical pre-analytical errors was 0.047%, with a Six Sigma value of 4.9. The total rate of sampling errors in the study period was 13.54% (P = 0.003). The highest rates were found for the indicators “haemolysed sample” (8.76%), “urine sample not submitted” (1.66%) and “clotted sample” (1.41%), with Six Sigma values of 3.7, 3.7 and 2.9, respectively.

Conclusions:

The magnitude of pre-analytical errors was accurately valued. While processes that triggered critical errors are well controlled, the results obtained for those regarding specimen collection are borderline unacceptable; this is particularly so for the indicator “haemolysed sample”.

Quality indicators in the preanalytical phase of testing in a stat laboratory

OBJECTIVE

To quantify performance in the preanalytical phase in a stat laboratory using quality indicators, and compare our results with those in the literature to improve laboratory services.

METHODS

We counted the test request forms, samples, and the types of preanalytical errors that occured in a stat laboratory between January 1 and December 31, 2011. We then compared the quality-indicator scores with the quality specifications mentioned in the literature.

RESULTS

During the 1-year period, a total of 168,728 samples and 88655 requests forms were received in stat laboratory. The total number of preanalytical errors was 1457, accounting for 0.8% of the total number of samples received in a year. Of the total preanalytical errors, 46.4% were hemolysed samples (biochemistry), 43.2% were clotted samples (hematology), 6.4% were samples lost-not received in the laboratory, 2.9% samples showed an inadequate sample-anticoagulant ratio, 0.7% were requests with errors in patient identification, 0.3% were samples collected in blood collection tubes with inappropriate anticoagulant and 0.1% were requests with errors--missing test requests.

CONCLUSION

The preanalytical performance of a stat laboratory in our setting is favorable and complies with international quality specifications.

Hematology point of care testing and laboratory errors: an example of multidisciplinary management at a children's hospital in northeast Italy

Involvement of health personnel in a medical audit can reduce the number of errors in laboratory medicine. The checked control of point of care testing (POCT) could be an answer to developing a better medical service in the emergency department and decreasing the time taken to report tests. The performance of sanitary personnel from different disciplines was studied over an 18-month period in a children’s hospital. Clinical errors in the emergency and laboratory departments were monitored by: nursing instruction using specific courses, POCT, and external quality control; improvement of test results and procedural accuracy; and reduction of hemolyzed and nonprotocol-conforming samples sent to the laboratory department. In January 2012, point of care testing (POCT) was instituted in three medical units (neonatology, resuscitation, delivery room) at the Children’s Hospital in Trieste, northeast Italy, for analysis of hematochemical samples. In the same period, during the months of January 2012 and June 2013, 1,600 samples sent to central laboratory and their related preanalytical errors were examined for accuracy. External quality control for POCT was also monitored in the emergency department; three meetings were held with physicians, nurses, and laboratory technicians to highlight problems, ie, preanalytical errors and analytical methodologies associated with POCT. During the study, there was an improvement in external quality control for POCT from −3 or −2 standard deviations or more to one standard deviation for all parameters. Of 800 samples examined in the laboratory in January 2012, we identified 64 preanalytical errors (8.0%); in June 2013, there were 17 preanalytical errors (2.1%), representing a significant decrease (P<0.05, χ² test). Multidisciplinary management and clinical audit can be used as tools to detect errors caused by organizational problems outside the laboratory and improve clinical and economic outcomes.

Short-term interventions on wards fail to reduce preanalytical errors: results of two prospective controlled trials

Background

Preventing laboratory errors promotes patient safety and reduces the cost of unnecessary processing. The aim of this study was to test the effectiveness of two short-term interventions at reducing errors in the preanalytical stage of laboratory testing.

Methods

Error data were reviewed from inpatient wards at Bradford Royal Infirmary (BRI), Leeds General Infirmary (LGI) and St James’ University Hospital (SJUH) for 22 weeks. Two separate interventions lasted for two weeks. The outcome measures were inadequate tube and form labelling, incorrect tube selection and insufficient sample volume. Posters targeting these errors were created and displayed on inpatient wards in SJUH ( n = 48). BRI and LGI were control hospitals. Qualitative interviews were held with clinical staff to raise awareness of common errors, give advice and discuss error reduction ( n = 37). Ten weeks later, screensavers warning against labelling errors were displayed (LGI and SJUH). Quantitative error data, routinely collected by the laboratory, were used for analysis.

Results

There was no change in error rate or type at the intervention site(s) compared with the control(s). There were 7058 reported errors across three sites, of which 6623 were errors targeted by the interventions. The overall error rate remained stable on all three sites (analysis of variance, P = 1.0). When interviewing clinical staff, 29% thought that equipment was the main contributing factor to errors while 23% struggled with tube selection.

Conclusions

Despite enthusiasm on the part of the ward-based staff, both short-term interventions had no significant impact on preanalytical error rates. Most errors are due to human factors. These may be reduced with the introduction of an electronic ordering system.

Exploring the Initial Steps of the Testing Process: Frequency and Nature of Pre-Preanalytic Errors

BACKGROUND

Few data are available on the nature of errors in the so-called pre-preanalytic phase, the initial steps of the testing process. We therefore sought to evaluate pre-preanalytic errors using a study design that enabled us to observe the initial procedures performed in the ward, from the physician's test request to the delivery of specimens in the clinical laboratory.

METHODS

After a 1-week direct observational phase designed to identify the operating procedures followed in 3 clinical wards, we recorded all nonconformities and errors occurring over a 6-month period. Overall, the study considered 8547 test requests, for which 15 917 blood sample tubes were collected and 52 982 tests undertaken.

RESULTS

No significant differences in error rates were found between the observational phase and the overall study period, but underfilling of coagulation tubes was found to occur more frequently in the direct observational phase (P = 0.043). In the overall study period, the frequency of errors was found to be particularly high regarding order transmission [29 916 parts per million (ppm)] and hemolysed samples (2537 ppm). The frequency of patient misidentification was 352 ppm, and the most frequent nonconformities were test requests recorded in the diary without the patient's name and failure to check the patient's identity at the time of blood draw.

CONCLUSION

The data collected in our study confirm the relative frequency of pre-preanalytic errors and underline the need to consensually prepare and adopt effective standard operating procedures in the initial steps of laboratory testing and to monitor compliance with these procedures over time.

Managing the pre- and post-analytical phases of the total testing process

For many years, the clinical laboratory's focus on analytical quality has resulted in an error rate of 4-5 sigma, which surpasses most other areas in healthcare. However, greater appreciation of the prevalence of errors in the pre- and post-analytical phases and their potential for patient harm has led to increasing requirements for laboratories to take greater responsibility for activities outside their immediate control. Accreditation bodies such as the Joint Commission International (JCI) and the College of American Pathologists (CAP) now require clear and effective procedures for patient/sample identification and communication of critical results. There are a variety of free on-line resources available to aid in managing the extra-analytical phase and the recent publication of quality indicators and proposed performance levels by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) working group on laboratory errors and patient safety provides particularly useful benchmarking data. Managing the extra-laboratory phase of the total testing cycle is the next challenge for laboratory medicine. By building on its existing quality management expertise, quantitative scientific background and familiarity with information technology, the clinical laboratory is well suited to play a greater role in reducing errors and improving patient safety outside the confines of the laboratory.

Pre-Analytical Workstations as a Tool for Reducing Laboratory Errors

Reducing errors and improving quality are an integral part of Laboratory Medicine. Laboratory testing, a highly complex process commonly called the total testing process (TTP), is usually subdivided into three traditional (pre-, intra-, and post-) analytical phases. A series of papers published from 1989 drew the attention of laboratory professionals to the pre-analytical phase, which currently appears to be more vulnerable to errors than the other phases. Consequently, the preanalytical phase should be the main target for further quality improvement. Therefore, identifying the critical steps in the pre-analytical phase is a prerequisite for continuous quality improvement, further error reduction and thus for improving patient safety. Use of automated systems where feasible, and use of error reduction/improved quality as a factor when selecting instrumentation are the main tools we have to insure high quality and minimize errors in the pre-analytical phase. The reasons for automation of the pre-analytical phase have become so compelling that it is no longer simply a competitive advantage for laboratories, but rather a competitive necessity. These systems can impact on the clinical/laboratory interface and affect the efficiency, effectiveness and quality of care.

Medical Errors: Pre-Analytical Issue in Patient Safety

The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories, while a growing body of evidence demonstrates that the pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. In particular, most errors are identified in pre-pre-analytic steps outside the walls of the laboratory, and beyond its control. However, in a patient-centred approach to the delivery of health care services, there is the need to investigate, in the total testing process, any possible defect that may have a negative impact on the patient, irrespective of which step is involved and whether the error depends on a laboratory professional (e.g. calibration or testing error) or a non-laboratory operator (e.g. inappropriate test request, error in patient identification and/or blood collection). In the pre-analytic phase, the frequency of patient/specimens misidentification and the presence of possible causes of specimen rejection (haemolysis, clotting, insufficient volume, etc.) represent a valuable risk for patient safety. Preventing errors in the pre-analytical steps requires both technological developments (wristband, barcodes, pre-analytical workstations) and closer relationships with the clinical world to achieve an effective team-working cooperation. The most important lesson we have learned, therefore, is that laboratory errors and injuries to patients can be prevented by redesigning systems that render it difficult for all caregivers and in all steps of the total testing process to make mistakes.

Diagnostic testing: the search for real evidence

A cornerstone in the quest for evidence is the use of diagnostic tests to determine the underlying issue for any symptoms seen in a patient. Clearly, diagnosis is not the final outcome in any patient scenario, but rather the beginning. The purpose of diagnostic testing is to provide evidence that will guide the health care provider in decision-making that will lead to achieving positive patient outcomes. This article provides a process by which a diagnostic test can be evaluated within the parameters of a patient condition. Through a thorough understanding of the test, the critical care nurse can be more effective in educating the patient, preparing the patient, and anticipating postprocedure nursing interventions for the patient undergoing diagnostic testing.

The detection and prevention of errors in laboratory medicine

The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories. Evidence demonstrates that pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. Most errors are identified in pre-pre-analytic and post-post-analytic steps outside of the laboratory. In a patient-centred approach to the delivery of health-care services, there is the need to investigate, in the TTP, any possible defect that may have a negative impact on the patient. In the interests of patients, any direct or indirect negative consequence related to a laboratory test must be considered, irrespective of which step is involved and whether the error depends on a laboratory professional (e.g. calibration/testing error) or non-laboratory operator (e.g. inappropriate test request, error in patient identification and/or blood collection). Patient misidentification and problems communicating results, which affect the delivery of diagnostic services, are recognized as the main goals for quality improvement. International initiatives aim at improving these aspects. Grading laboratory errors on the basis of their seriousness should help identify priorities for quality improvement and encourage a focus on corrective/preventive actions. It is important to consider not only the actual patient harm sustained but also the potential worst-case outcome if such an error were to reoccur. The most important lessons we have learned are that system theory also applies to laboratory testing and that errors and injuries can be prevented by redesigning systems that render it difficult for all health-care professionals to make mistakes.

Applicability and potential benefits of benchmarking in Brazilian clinical laboratory services

Purpose

The purpose of this paper is to test the applicability and benefits of benchmarking as a tool for quality analysis in Brazilian laboratory medical services.

Design/methodology/approach

A primary observational study is performed in eight hospital laboratories by tracking the receipt, analysis and return to participants of monitoring reports relating to several quality indicators for the years 2005 and 2006. Whenever possible, the paper applies 6σ criteria as an independent assessment of process quality.

Findings

Data obtained for the eight laboratories showed a monthly average (±SD) of 178,579 (±153,670) tests performed per laboratory, with 40,256 (±44,858) requisitions and 4.77 (±1.33) tests per requisition. Overall, productivity was 7.35 (±2.46) tests per man‐hour of work (MHW), increasing to 15.36 (±6.00) when considering only the analytical sector staff. An average of 1.63 (±1.14) lost hours per hundred MHW were reported (level 3.6σ), with 3.86 (±5.10) accidents at work reported (AWR) per hundred thousand MHW (level 5.5σ) and 4.22 (±2.61) redraws per thousand requisitions attended (level 4.1σ). The turn‐around‐times were 2.25 (±0.98), 3.29 (±2.12) and 8.54 (±3.25) hours for glucose level, haemogram and human immunodeficiency virus serology, respectively.

Practical implications

Benchmarking proved to be a useful and feasible tool for quality management in Brazilian clinical laboratories, particularly when associated with independent tools for evaluating the quality of laboratorial processes.

Originality/value

This is the first Brazilian study reporting that benchmarking provides useful information on the performance of different clinical laboratory processes and, therefore, could become an important tool for laboratory management.

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics

Laboratory diagnostics, a pivotal part of clinical decision making, is no safer than other areas of healthcare, with most errors occurring in the manually intensive preanalytical process. Patient misidentification errors are potentially associated with the worst clinical outcome due to the potential for misdiagnosis and inappropriate therapy. While it is misleadingly assumed that identification errors occur at a low frequency in clinical laboratories, misidentification of general laboratory specimens is around 1% and can produce serious harm to patients, when not promptly detected. This article focuses on this challenging issue, providing an overview on the prevalence and leading causes of identification errors, analyzing the potential adverse consequences, and providing tentative guidelines for detection and prevention based on direct-positive identification, the use of information technology for data entry, automated systems for patient identification and specimen labeling, two or more identifiers during sample collection and delta check technology to identify significant variance of results from historical values. Once misidentification is detected, rejection and recollection is the most suitable approach to manage the specimen.

Exploring the iceberg of errors in laboratory medicine

The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories, and currently available evidence demonstrates that the pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. In particular, most errors are identified in pre-pre-analytic and post-post analytic steps outside the walls of the laboratory, and beyond its control. However, in a patient-centered approach to the delivery of health care services, there is the need to investigate any possible defect in the total testing process that may have a negative impact on the patient. In fact, in the interests of patients, any direct or indirect negative consequence related to a laboratory test must be considered, irrespective of which step is involved and whether the error is caused by a laboratory professional (e.g., calibration or testing error) or by a non-laboratory operator (e.g., inappropriate test request, error in patient identification and/or blood collection). Data on diagnostic errors in primary care and in the emergency department setting demonstrate that inappropriate test requesting and incorrect interpretation account for a large percentage of total errors whatever the discipline involved, be it radiology, pathology or laboratory medicine. Patient misidentification and problems in communicating results, which affect the delivery of all diagnostic services, are widely recognized as the main goals for quality improvement. Therefore, some common problems affect diagnostic errors, although specific faults characterising errors in laboratory medicine should lead to preventive and corrective actions if evidence-based quality indicators are developed, implemented and monitored. The lesson we have learned is that each practice must examine its own total testing process to discover its weaknesses and identify appropriate remedies.

Does POCT reduce the risk of error in laboratory testing?

Point-of-care testing (POCT), the fastest growing segment of the current clinical laboratory testing market, is a rapid means for providing test results in different clinical settings. In theory, this tool eliminates some of the more problematic steps in the testing process, including specimen transport and result distribution. However, POCT has created new challenges, and sources of potential errors; moreover, while the upsurge in its use has generated concerns regarding the quality of test results, few data are available in the literature on errors with POCT. Nor are data available for the evaluation of errors, and the risk of errors in POCT based on all steps in the entire testing process, including test requesting and result utilization. According to a modified Kost model, which takes into account all steps of the testing process and latent conditions for error, POCT reduces errors and the risk of error in only a few steps of the testing process. There is therefore an urgent need for an evaluation of errors and risks of error in POCT that is based on the entire testing process and uses well-designed studies aiming to improve clinical outcomes and increase patient safety.

Reference ranges and diagnostic thresholds of laboratory markers of cardiac damage and dysfunction in a population of apparently healthy black Africans

BACKGROUND

Due to the increasing migration flows mostly concerning Western countries, the problem of reference ranges and cut-off values is a living matter. In particular, the influence of ethnic origin on traditional and novel biochemical markers of cardiac damage, including cardiac troponin T (cTnT), ischemia modified albumin (IMA) and N-terminal prohormone brain natriuretic peptide (NT-proBNP), has not been investigated, to the best of our knowledge.

METHODS

CTnT, NT-proBNP and IMA were assayed by a Modular System in 34 apparently healthy black Africans originating mainly from Central Africa and in 34 apparently healthy white, non-immigrant Italians, matched for age and sex.

RESULTS

All the subjects investigated displayed cTnT values < 0.01 ng/mL. Black Africans displayed significantly increased concentrations of serum IMA (107 vs. 92 kU/L, p < 0.0001), but not of NT-proBNP (4.9 vs. 3.8 pmol/L, p = 0.4), as compared to the white, nonimmigrant Italians.

CONCLUSIONS

The results of our investigation indicate that the reference ranges and the thresholds values of IMA, but not those of cTnT and NT-proBNP, may be different according to the ethnic origin of the population. Therefore, although the current decisional thresholds of both cTnT and NT-proBNP may be appropriate for diagnosing cardiac damage and dysfunction in the black African population, that of IMA may require a revision toward higher values.

Influence of the centrifuge time of primary plasma tubes on routine coagulation testing

Preparation of blood specimens is a major bottleneck in the laboratory throughput. Reliable strategies for reducing the time required for specimen processing without affecting quality should be acknowledged, especially for laboratories performing stat analyses. The present investigation was planned to establish a minimal suitable centrifuge time for primary samples collected for routine coagulation testing. Five sequential primary vacuum tubes containing 0.109 mol/l buffered trisodium citrate were collected from 10 volunteers and were immediately centrifuged on a conventional centrifuge at 1500 x g, at room temperature for 1, 2, 5, 10 and 15 min, respectively. Hematological and routine coagulation testing, including prothrombin time, activated partial thromboplastin time and fibrinogen, were performed. The centrifugation time was inversely associated with residual blood cell elements in plasma, especially platelets. Statistically significant variations from the reference 15-min centrifuge specimens were observed for fibrinogen in samples centrifuged for 5 min at most and for the activated partial thromboplastin time in samples centrifuged for 2 min at most. Meaningful biases related to the desirable bias were observed for fibrinogen in samples centrifuged for 2 min at most, and for the activated partial thromboplastin time in samples centrifuged for 1 min at most. According to our experimental conditions, a 5-10 min centrifuge time at 1500 x g may be suitable for primary tubes collected for routine coagulation testing.

Risk management in the preanalytical phase of laboratory testing

The clinical laboratory is no longer its own limited ecosystem, as it is increasingly integrated with patient care, assisting diagnosis, monitoring therapies and predicting clinical outcomes. Although efforts and resources are continuously focused to achieve a satisfactory degree of analytical quality, there is clear evidence that the preanalytical phase is much more vulnerable to uncertainties and accidents, which can substantially influence patient care. Most errors within the preanalytical phase result from system flaws and insufficient audit of the operators involved in specimen collection and handling responsibilities, leading to an unacceptable number of unsuitable specimens due to in vitro hemolysis, clotting, insufficient volume, wrong container, contamination and misidentification. A reliable approach to overcome this problem entails prediction of accidental events (exhaustive process analysis, reassessment and rearrangement of quality requirements, dissemination of operating guidelines and best-practice recommendations, reduction of complexity and error-prone activities, introduction of error-tracking systems and continuous monitoring of performances), an increase in and diversification of defenses (application of multiple and heterogeneous systems to identify non-conformities), and a decrease in vulnerability (implementation of reliable and objective detection systems and causal relation charts, education and training). This policy, which requires integration between requirements and design, full commitment and interdepartmental cooperation, should make laboratory activity more compliant to the inalienable paradigm of total quality in the testing process.

Clin Chem Lab Med 2007;45:720–7.

Errors in laboratory medicine and patient safety: the road ahead

The Institute of Medicine (IOM) report,

Clin Chem Lab Med 2007;45:700–7.