Laboratory errors as judged by test request slips and test reports.

Abstract

To evaluate common laboratory transcription errors made in requisition forms and rate of report failure in test result reports. Descriptive study. Jinnah Postgraduate Medical Center (JPMC) from February 01, till February 28, 2002. One hundred and eight patient s records were collected randomly from 24 different departments of the hospital, during the month of February 2002. Each record was scrutinized for requisition slips and test reports. Tabulation of the content matter of all requisition slips and the test reports was done on the spread sheet, for the transcription errors; and compared with the minimum standards of requisition forms, as laid down by clinical laboratory improvement amendments; 1988 (CLIA 88). Request forms on which urgent test/any comment was given, were tabulated separately. Differences in the number of tests ordered and actually performed were also tabulated. Percentage of error was calculated. Four hundred and sixty-nine test request forms, requesting 1112 tests, were analyzed. None of them had pre-formatted laboratory forms. They were written on torn file papers, Out-patient department (OPD) slips and plain papers. The transcription errors included physician s identification errors (469/469 or 100%), patient s name, age, sex and unique identifier errors (0, 94, 95 and 81%) respectively, error in patients data aiding diagnosis (100%) and report failure error (37%). The requesting pattern of the laboratory tests ordered by clinicians revealed inclination towards panel-test ordering. The results of requested tests were available in 63% requested tests, and not available in 37% tests. No reason for rejection of the specimen was found on feed-back/report. Further analysis of un-reported results revealed that the emergency tests of electrolytes and sugar were the most affected ones, followed by PT/APTT, ESR and urine analysis. Tests for serum electrolytes done in elective and emergency setup, showed that out of 152 test requests for electrolytes, 124 requests were sent in elective and 28 in emergency setup. There was report failure in 84 cases (67.7%) in former and 13 cases (46.4%) in the latter. A good insight on error-prone steps in the laboratory process is essential to achieve error reduction; hence, in addition to maintaining quality standards within laboratory, it is imperative to go outside the laboratory to identify the common errors made in laboratory process and to reorganize the activity of the wards.