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Am J Med Qual. 2012 Mar-Apr;27(2):147-53. doi: 10.1177/1062860611413567. Epub 2011 Sep 14.

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

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1
Tufts Medical Center, Boston, MA 02111, USA.

Abstract

Laboratory testing is essential for diagnosis, evaluation, and management. The objective was to describe the type of laboratory events reported in hospitals using a voluntary electronic error reporting system (e-ERS) via a cross-sectional analysis of reported laboratory events from 30 health organizations throughout the United States (January 1, 2000, to December 31, 2005). A total of 37,532 laboratory-related events were reported, accounting for 14.1% of all reported quality events. Preanalytic laboratory events were the most common (81.1%); the top 3 were specimen not labeled (18.7%), specimen mislabeled (16.3%), and improper collection (13.2%). A small number (0.08%) of laboratory events caused permanent harm or death; 8% caused temporary harm. Most laboratory events (55%) did not cause harm. Laboratory errors constitute 1 of 7 quality events. Laboratory errors often are caused by events that precede specimen arrival in the lab and should be preventable with a better labeling processes and education. Most laboratory errors do not lead to patient harm.

PMID:
21918013
DOI:
10.1177/1062860611413567
[Indexed for MEDLINE]

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