Clerical Errors Research Articles

IMMUNOHEMATOLOGY: Identification and evaluation of false‐negative antibody screens

Background: Non‐ABO alloantibodies are frequently implicated in hemolytic transfusion reactions and are a leading cause of transfusion‐related mortality. Detection of clinically significant non‐ABO alloantibodies is reliant on an antibody screen, which is prone to clerical, technical, and reagent error. Data on the frequency of false‐negative antibody screens due to the occurrence of these errors are scarce, and the true incidence of false‐negative antibody screens in everyday practice is unknown.STUDY DESIGN AND METHODS: Monitoring for false‐negative antibody screens is routinely performed in our institution. All cases of false‐negative antibody screens involving clinically significant antibodies were identified through review of the blood bank quality assurance records from 2004 to 2007. The clinical impact was recorded in each case.RESULTS: Twenty‐one cases of false‐negative antibody screens due to clinically significant antibodies were detected. Sources of error included testing error (12 cases), reagent red blood cell (RBC) failure (one case), and reagent limitations (one case). The cause of error was inconclusive in seven cases. Nine patients were found to have received antigen‐incompatible blood as a consequence of these errors, resulting in a single nonfatal hemolytic transfusion reaction.CONCLUSIONS: The identification and investigation of false‐negative antibody screens is a valuable quality assurance measure which can serve to monitor staff performance, identify cases of reagent RBC failure, and identify patients who have received antigen‐incompatible blood at risk for hemolytic transfusion reactions.

Pre- and post-analytical errors in the RCPA microbiology quality assurance program 1987–2008

Objective To report on the frequency of pre- and post-analytical errors by participants in the Royal College of Pathologists of Australasia (RCPA) Microbiology Quality Assurance Programe (MQAP). Methods Retrospective review of MQAP data 1987–1991 and 2004–2008. Pre-analytical errors rates were based on participants’ detection rate of clerical errors for patient name and identification number for the given test item. Fictitious errors were defined as the reporting of a labelling error when in fact there was no discrepancy. Post-analytical errors rates were based on clear transcription errors resulting in the test result being incorrectly assigned to another test item. Results When there was one clerical error a median of 9% (range 2–27%) of participants failed to report it. When there were two errors 6% (range 0–29%) failed to report either error. A median of 0.7% (range 0–6%) of participants reported fictitious errors. Of the 83 items where direct transposition errors were possible 54 (65%) had at least one participant who transcribed the results. Pre-analytical errors have not decreased over time. Conclusions Pre- and post-analytical errors are not rare amongst participants in the RCPA MQAP. These non-analytical components of the testing pathway require improvement.

But Doctor, I Still Have Both Feet! Remedial Problems Faced by Victims of Medical Identity Theft

When Lind Weaver starting receiving collections demands for a foot amputation she never had, she assumed it was a clerical error. Unfortunately, the operation had been performed on someone pretending to be Weaver, causing Weaver's medical history to become entangled in the thief’s. Media reports about identity theft show Weaver's experience is far from unique. For example, a Chicago man was arrested after using his friend's identity to obtain $350,000 worth of cardiovascular surgery at a local hospital. Hackers broke into the medical records of thousands of University of California students. A staff member left a laptop containing records of patients of a local AIDS clinic on Boston public transportation.

Transfusion errors and management

Error is an inherent component and an intrinsic by-productof every activity in which humans are involved. This ten-dency to err is philosophically perhaps one of the definingtraits that characterize us as human beings. Transfusionerrors probably existed once blood transfusion became anessential component of medical treatment. However, thesystematic acknowledgement, recognition and analysis ofthese errors are certainly a much more recent phenomenon.According to an Institute of Medicine (IOM) reportreleased in 1999 [1], medical errors are one of the leadingcause of death in the US and have caused an estimated44 000–98 000 deaths per year, which is soberingly morethan the motor vehicle accident death rate of 43 458 forthat particular year.Errors and adverse events carry a high financial burden.The Agency of Healthcare Research and Quality (AHRQ)estimated that the cost of medical errors resulting inadverse events is approximately $37AE6 billion per year, and$17 billion of those costs are preventable [1]. Significantly,the AHRQ has reported that medical errors are not onlybecause of medication errors but can result from bloodtransfusion errors, misdiagnosis, misinterpretation of labo-ratory results with incorrect therapy, equipment failure,hospital acquired infections or misinterpretation medicalorders.Looking specifically at transfusion mortality, Schmidtreviewed 69 records of deaths labelled as transfusion mor-tality and concluded that 31 (44AE9%) were directly attribut-able to transfusion, of which 25 were due to red cellincompatibilities and discrepancies [2]. Myhre reviewed113 records fatalities reported to the Food and DrugAdministration (FDA) as a sequelae of blood or blood prod-uct transfusion from 3 April 1976 to 31 December 1979 [3].Thirty-three fatalities were due to post-transfusion hepati-tis, and three involved plasmapheresis or leucopheresisdonors. The remaining 77 cases were of three categories:the vast majority were preventable errors: 47 cases (61%)were due to ‘‘clerical errors’’ such as drawing the wrongblood specimen or giving the wrong unit of blood to thepatient; 8 cases consisted of genuine errors that occurred inthe laboratory and 22 miscellaneous cases.Many other recent reports exist with the majority retro-spective and involving registry data (e.g. reporting to theFDA). Honig and Bove listed 70 fatalities, 38 of which weredue to transfusion errors [4]. Camp and Monaghan studied126 FDA reports from 1976 through 1980. They found that64 reactions that were due to simple clerical errors, such asgiving the blood to the wrong patient [5].In a landmark paper, Sazama and colleagues studiedtransfusion-related deaths reported to the US FDA for10 years and identified 131 fatal ABO incompatible trans-fusions. The study showed that the most frequent errorleading to a fatal outcome was administration to someoneother than the intended recipient [6]. Records of transfusionerrors in the New York State for the past 10 years (Linden)showed that erroneous blood administration was observedin 1 out of 19 000 RBC units administered. Half of theseevents occurred outside the blood bank (administration tothe wrong recipient, phlebotomy errors, testing of thewrong specimen, transcription errors and issuance of thewrong unit) with 15% of cases involving multiple errors [7].McClelland and Phillips conducted a study and analysedthe data from haematology laboratories in the UK for theyears 1990 and 1991. They sent a questionnaire to 400 lab-oratories involved in blood transfusion and only 245 (61%)submitted their reply. The reports included data on deaths,morbidity and near misses. One-third of the laboratoriesreported incidents in which the patient received a wrongunit of blood [8].

Reply: Timing of brain damage and verbal-performance IQ tilts

Sir, Many thanks for providing the opportunity to respond to the letter from Dr Gordon concerning our recent paper: Childhood brain insult: can age at insult help us predict outcome? (Anderson et al. , 2009). We are grateful for the chance to clarify the issues raised. The first point raised by Gordon (2009) correctly identified an error in the data presented in Table 5 of our paper. This error has been acknowledged and addressed separately in a recent Corrigendum published in Brain . Importantly, this was a clerical error regarding labelling of variables within the table. Interpretation of the results and data were not impacted by this error. The second issue of the contention relates to our finding that verbal IQ (VIQ) was consistently less than performance IQ (PIQ) in all groups in our sample. Subsequent analyses confirm …

Enhancing Transfusion Safety with an Innovative Bar-Code-Based Tracking System

In an effort to reduce transfusion errors, a novel, comprehensive, computerized wireless bar-code-based tracking system for matching patients, blood samples and blood products was created and deployed at a major academic medical centre. With a grant from the Agency for Healthcare Research and Quality, software was developed to track scans at the times of sample collection, sample arrival in the blood bank, blood product dispensation from the blood bank and blood product administration. The system was deployed in February 2005. The system was well accepted from the outset, and the sample rejection rate due to clerical errors fell from 1.82 to 0.17%; incident reports fell by 83%. At the final blood administration step, the accumulated data as of November 2008 indicated that identification errors were being detected and prevented every 42.4 days and that the scan completion rate was stable at about 99%. Process analysis suggested that these were independent events and, thus, would be expected to coincide (and potentially produce a mis-transfusion) every 4,240 days (11.6 years) on average. We estimate that the system is 10 times safer than the manual system previously employed at our institution and may be 15-20 times safer than most systems employed in the United States.

Clinic appointment reminders among rheumatology patients

Dear Editor, We read with interest the publication by Hogan AM et al. [1], which looked at the potential impact of text message reminders on non-attendance at surgical outpatient (OPD) clinics in Ireland and reported that such a service would encourage 51% to attend or cancel their missed OPD appointment. As the authors pointed out, little work has been carried out in this area in Ireland. Recently, we also examined the topic, focusing on Rheumatology patients attending our outpatient services, who had a ‘‘did not attend’’ (DNA) rate of almost 18% (525/2,924) in 2007 [2] compared to 16.8% in the Hogan AM et al. study. Many patients DNA their OPD clinic appointments for one reason or another, for example a lapse in memory or forgetfulness has been estimated for up to 50% of DNA cases [3, 4]. The level of DNA can be extremely high in many departments. In the department of care for the elderly at Hammersmith Hospital, London, in 1996–1997, DNA rates were a staggering 21% [5]. This is at the backdrop of a national mean DNA rate of 12% for all clinics in the UK for the same period [6]. These results compare to 16% forgetting their appointment in Hogan et al. with 20% due to clerical errors. DNA has many implications for both the patients and the services involved. Regarding the patient, missed valuable clinical input may result in suboptimal health. This is very well documented among the diabetic population where patients who DNA clinic appointments have significantly greater risk factors and complications from their chronic condition [7]. Focusing on the services provided, the implications include vacant clinic appointments, which can be a waste of scarce financial resources. In our study, we conducted a cross-sectional selfadministered anonymous questionnaire with 166 patients (159 return patients) who attended Rheumatology clinics at the South Infirmary, Victoria University Hospital, Cork, Ireland. Patients were recruited intermittently, but consecutively, while the researchers were in attendance between September and October 2007. A response rate of 98% (163/166) was achieved. New patients were not analysed due to low numbers. Ninety-eight percentage (156/ 159) of return patients responded. Overall, 99% felt OPD appointment reminders to be a good idea. Interestingly, on logical regression analysis, those who had previously attended OPD were significantly more likely to view reminders as a positive idea (P \ 0.0005, OR = 57.72, 95% CI 15.14–220.03). This may suggest that those who have had more OPD exposure appreciate the possibility of missed appointments and the benefits of reminders. These findings were recorded in a setting of 65% (104), 16% (26), 96% (153), 59% (94), and 46% (73) having competence in or access to a mobile phone SMS, e-mail, a landline telephone, a landline voice messaging service and a mobile phone voice messaging service, respectively. Text/SMS messaging (47%) is the most preferred method of appointment reminder followed by a telephone call (26%) and postal letter (25%). The mean age of those M. B. O’Connor (&) Department of Medicine, South Infirmary-Victoria University Hospital, Old Blackrock Road, Cork, Ireland e-mail: mortimeroconnor@gmail.com

Stylized Facts and Incentive Effects Related to Claiming of Retirement Benefits Based on Social Security Administration Data

We rely on the Master Beneficiary File to document a number of facts regarding claiming of Social Security benefits and quality of date of birth data in administrative files. We then assess the impact of changes in retirement incentives that have taken place since 2000 on claiming. We find evidence of non-trivial misreporting or clerical errors in the dates of births that give rise to systematic patterns but nevertheless appear to be fairly random. We also confirm significant tendency to claim in January or on birthdays, but we find that these patterns are still sensitive to incentive effects. Relying on the discontinuity in the Early Entitlement Age that occurs for people born on the second day of any month, we find evidence that people do not have single-peaked preferences over claiming age: relaxing the early retirement constraint leads to acceleration of retirement by some people for whom the constraint would not be otherwise binding. One possible explanation for this pattern is a preference for retiring at one's birthday. We take advantage of a change in the full retirement age and find that there remains unusually large (relative to other birthdays) number of people who claim around their 65th birthday, supporting the idea that Medicare eligibility has an impact on claiming retirement benefits. Finally, we confirm that elimination of the earnings test in 2000 for those above full retirement age accelerated retirements and find that it also led to a significant weakening of the January effect in that group, bolstering the idea that the January effect is sensitive to economic incentives.

Factors Associated with Peripheral Blood Stem Cell Yield in Volunteer Donors Mobilized with Granulocyte Colony-Stimulating Factors: The Impact of Donor Characteristics and Procedural Settings

Peripheral blood stem cells (PBSCs) are increasingly used as the source of hematopoietic stem cells, but there are large variations in harvest outcome between individuals mobilized by granulocyte colony-stimulating factor (G-CSF). We examined the effects of donor characteristics and procedure factors on the day 1 CD34+ cell yield in 373 unrelated healthy donors. G-CSF was administered subcutaneously at a planned dose of 8.3 to 11 microg/kg daily for 5 days, followed by harvest started on day 5 of G-CSF treatment. Of the 373 donors, 159 (42.6%) had the radial artery as the inlet access for harvest. Poor day 1 cell yield was defined as <10x10(6) CD34+ cells/L of processed blood for the first apheresis; 62 donors (16.6%) did not attain this threshold. The male donors had significantly higher yields at harvest compared with the female donors. The female donors had higher CD34+ cell yields if the circulation access was through an artery than if is was through a vein. In a multiple regression analysis, donor age, sex, body mass index (BMI), preharvest white blood cell and circulating immature cell counts, access type, and flow rate correlated with day 1 yield. Female sex, older age, venous access, and a higher flow rate were significantly associated with greater risk for a day 1 poor yield of CD34+ cells (odds ratio=3.0074, 1.045, 4.3362, and 1.1131, respectively). A higher BMI may decrease the risk (odds ratio=0.8472). In donors at higher risk for poor CD34+ cell yield, strategies for increasing CD34+ cells must be considered.

Texting appointment reminders to repeated non-attenders in primary care: randomised controlled study

Background:Failure to attend appointments compromises health service efficiency. Despite considerable interest in using novel technologies to improve attendance, evidence from rigorously conducted controlled studies is lacking.Aim:To evaluate the effectiveness of...

Correction to “Aerosol and fresh snow chemistry in the East Rongbuk Glacier on the northern slope of Mt. Qomolangma (Everest)”

[1] In the paper ‘‘Aerosol and fresh snow chemistry in the East Rongbuk Glacier on the northern slope of Mt. Qomolangma (Everest)’’ by J. Ming et al. (Journal of Geophysical Research, 112, D15307, doi:10.1029/2007JD008618, 2007), there is a clerical error on page 3, paragraph 13, line 3. The ‘‘3.34’’ should be corrected to ‘‘0.34.’’ This clerical error does not influence calculations or conclusions presented in the paper at all because other results in the paper are calculated on the basis of the correct number ‘‘0.34.’’ JOURNAL OF GEOPHYSICAL RESEARCH, VOL. 113, D15306, doi:10.1029/2008JD010430, 2008 Click Here for Full Article

Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital

The Japanese Society of Anesthesiologists (JSA) has investigated critical events in several fields of anesthesiology. However, the types, frequency, and characteristics of medication errors related to anesthesia have not been investigated. By analyzing incident reports retrospectively, we investigated medication errors that occurred during anesthetic practice over the past 8 years at our institution. Incident reports related to medication errors that occurred between May 1999 and March 2007 were analyzed retrospectively using a questionnaire published by the JSA in the "Survey of medication errors related to anesthesia". During these 8 years, 233 incidents were reported, in a total of 27454 anesthesia cases conducted during this period. Of these incidents, 61 (26.2%) were anesthetic drug administration errors. In these 61 incidents, clerical error (e.g., erroneous prescription writing), and pre-error (defined as any incident with the potential to become an error) were excluded from the analysis. Consequently, 13 incidents were excluded and 48 incidents were analyzed. Medication errors due to overdose were the most frequent kind of error (25%), followed by substitution (23%), and omission (21%). Errors due to an incorrect route of administration were rare. The drugs most frequently involved in these errors were antibiotics and muscle relaxants. Most of the patients involved in the incidents were, fortunately, not harmed seriously. The total frequency of medication errors in the survey period was 0.175% (48 incidents in 27 454 total anesthesia cases). We found that overdose, substitution, and omission were the main causes of anesthesia-related medication errors in our department.

An index‐based short form of the WAIS‐III with accompanying analysis of reliability and abnormality of differences

To develop an index-based, seven subtest, short form of the WAIS-III that offers the same comprehensive range of analytic methods available for the full-length version. Psychometric. The short-form indices had high reliability and criterion validity. Scores are expressed as index scores and as percentiles. Methods are provided that allow setting of confidence limits on scores, and analysis of the reliability and abnormality of index score differences. A computer program that automates scoring and implements all the analytical methods accompanies this paper and can be downloaded from the following web address: http://www.abdn.ac.uk/ approximately psy086/Dept/sf_wais3.htm. The short form will be useful when pressure of time or client fatigue precludes use of a full-length WAIS-III. The accompanying computer program scores and analyses an individual's performance on the short form instantaneously and minimizes the chance of clerical error.

Too much, too little, too soon, too late? Transfusion and long‐term survival in children

Too much, too little, too soon, too late? Transfusion and long‐term survival in children

Strategies and technical challenges in allele level Class II typing in 2578 bone marrow transplantation donor–recipient pairs

Human leukocyte antigen typing of 2578 donor-recipient pairs whose transplantation was facilitated by the National Marrow Donor Program allowed for an in-depth analysis of the accuracy of high-volume allele level testing data. The methods employed provided allele level typing at DRB1/3/5, DQA1, DQB1, DPA1, and DPB1 using sequence-specific oligonucleotide probe hybridization (SSOPH), polymerase chain reaction (PCR) restriction fragment length polymorphism analysis, sequence specific PCR, and direct sequence-based typing (SBT). Each typing was independently tested by two laboratories in Phase 1, and in subsequent phases targeted samples were typed in duplicate by SBT to monitor typing quality. Comparison with prior transplant center typing was also evaluated. SSOPH detected discrepancies ranged from 0.6% at DPB1 to 5.1% at DQB1 in Phase 1. The majority of discrepancies, 62%, resulted from human error such as sample handling, result interpretation, or clerical errors. Alleles that are frequently discrepant have been identified in this predominantly white population.

Rejoinder to Goldberg, Lee and Ashton (2008): explaining counterintuitive findings

In their critique of our erratum and addendum (Anderson &amp; Ones, 2008), Goldberg, Lee, and Ashton (2008) allege clerical errors (1) where participants' HPI scores were incorrectly matched to other inventory scale scores and (2) in scoring of the OPQ and BPI scales. The first point was fully addressed by our erratum and addendum and Goldberg et al. do not present any new evidence that was not already considered. In this response, we further demonstrate that Goldberg et al. do not and cannot prove clerical errors in scoring OPQ and BPI scales. The circumstantial arguments presented by Goldberg et al. are shown to be fallacious. We respond to all conjectures and criticisms raised by their paper. We acknowledge, as we did in our previous publication (Anderson &amp; Ones, 2003) that some of the specific convergent correlations and findings reported are not normative, but nonetheless explainable given psychometric and statistical artefacts that influence individual primary study results. Even basing our analyses upon the ‘reconstituted’ dataset generated and preferred by Goldberg et al., we demonstrate that our original conclusions do not change substantially. Responsible science requires the publication of all results, not only those confirming extant hypotheses and expectations. We continue to stand by the findings and conclusions reported in our previous publications (Anderson &amp; Ones, 2003; Ones &amp; Anderson, 2002). Copyright © 2008 John Wiley &amp; Sons, Ltd.

Development and Evaluation of a Diagnostic Documentation Support System using Knowledge Processing

In this paper, we will introduce a system which supports creating diagnostic reports. Diagnostic reports are documents by doctors of radiology describing the existence and nonexistence of abnormalities from the inspection images, such as CT and MRI, and summarize a patient's state and disease. Our system indicates insufficiencies in these reports created by younger doctors, by using knowledge processing based on a medical knowledge dictionary. These indications are not only clerical errors, but the system also analyzes the purpose of the inspection and determines whether a comparison with a former inspection is required, or whether there is any shortage in description. We verified our system by using actual data of 2,233 report pairs, a pair comprised of a report written by a younger doctor and a check result of the report by an experienced doctor. The results of the verification showed that the rules of string analysis for detecting clerical errors and sentence wordiness obtained a recall of over 90% and a precision of over 75%. Moreover, the rules based on a medical knowledge dictionary for detecting the lack of required comparison with a former inspection and the shortage in description for the inspection purpose obtained a recall of over 70%. From these results, we confirmed that our system contributes to the quality improvement of diagnostic reports. We expect that our system can comprehensively support diagnostic documentations by cooperating with the interface which refers to inspection images or past reports.

Debt Weight: The Consumer Credit Crisis in New York City and Its Impact on the Working Poor

The number of consumer debt cases filed in New York City Civil Court has exploded in recent years. In 2006 alone, approximately 320,000 such cases were filed in the five boroughs; this number is comparable to the total number of civil and criminal cases filed in the federal trial courts nationwide that year. Almost $1 billion in claims were made against New York City residents in consumer debt filings in 2006; in that year, we estimate that creditors ultimately obtained judgments of almost $800 million. In many ways, New York City Civil Court has become the “credit card court”, with a majority of the cases filed throughout the five boroughs classified as consumer debt cases. The impact of this judgment debt is profound. Once a judgment is obtained by a creditor against a debtor, the situation goes from bad to tragic. A creditor with a judgment can garnish wages and freeze bank accounts. Often, due to additional penalties, interest, fees and costs, the ultimate judgment obtained far exceeds any original debt that might have accrued. Sometimes, the defendant never owed the alleged debt, which may have been the result of identify theft, mistaken identity, clerical errors, or illegal fees and charges. Once an account is frozen, a debtor under such a crushing weight may be unable to pay rent bills, utilities, obtain medicine and pay for food and other necessities. A judgment will invariably show up on credit reports and such a black mark on a credit report will make it more difficult to find an apartment, get a better job, and obtain credit. For the working poor, the judgment blocks their climb up the economic ladder, and they cannot obtain better housing or a better job, or get a loan for a car or home. The total amount of judgments obtained against city residents in 2006, approximately $800 million, is the equivalent of building one new stadium for the Mets every year. Against this backdrop, this report is an attempt to understand the manner in which creditors are using the Civil Court of the City of New York to collect debts. To this end, the Urban Justice Center reviewed 600 randomly selected cases, all filed in February of 2006, in the five borough courthouses of the Civil Part of New York City Civil Court. The results of our research are striking.

No Relief Yet From Medicare Physician Pay Cuts

No Relief Yet From Medicare Physician Pay Cuts

A RhD Negative Patient Failed to Produce Detectable Anti-D after Transfusion of 35 Units of RhD Positive Red Blood Cells

In the present day, pretransfusion tests include ABO and RhD grouping, antibody screening, antibody identification, and cross matching. Although error rates for these tests have decreased compared to those in the past, clerical errors still occur. When exposed to RhD positive RBCs, a RhD negative person can produce anti-D that causes a severe hemolytic disease of the fetus and the newborn in addition to hemolytic transfusion reactions. Therefore, administration of RhD positive RBCs to a RhD negative person should be avoided. We experienced a RhD negative patient who had been misidentified as positive and transfused 35 units of RhD positive RBCs eight years ago, but did not have detectable anti-D in present. The red cells of the patient showed no agglutination with the anti-D reagent and a negative result in the standard weak D test. The multiplex PCR with sequence-specific priming revealed that the patient was RhD negative.