Phlebotomy Error Cost
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Pre-analytical errors: their impact and how to minimize them By: Nitin Kaushik By: Sol Green May 18, 2014 0 14968 The clinical laboratory plays an increasingly important role in the patient-centered approach to pre analytical error in laboratory the delivery of healthcare services. Physicians rely on accurate laboratory test results for
Pre Analytical Error Definition
proper disease diagnosis and for guiding therapy; it is estimated that more than 70% of clinical decisions are based post analytical error on information derived from laboratory test results.1 The process of blood testing, also known as the “Total Testing Process,” begins and ends with the patient. It includes the entire process from ordering preanalytical errors in phlebotomy the test to interpretation of the test results by the clinician. The Total Testing Process can be subdivided into three stages: Pre-analytical: test request, patient and specimen identification, specimen collection, transport, accessioning and processing Analytical: specimen testing Post-analytical: reporting test results, interpretation, follow up, storage, retesting if needed. Additionally, the term “pre-pre-analytical phase” has been used for the initial part of the pre-analytical phase, focused
Mislabeled Lab Specimens
on test selection and identification of test needed, and the term “post-post-analytical phase” has been used for the interpretation of results by the clinician.2 The numbers don’t lie: it’s a significant problem Clinical laboratory errors directly lead to increased healthcare costs and decreased patient satisfaction. A laboratory error is defined as any defect that occurs during the entire testing process, from ordering tests to reporting results, that in any way influences the quality of laboratory services.3 Any error during the laboratory testing process can affect patient care, including delay in reporting, unnecessary redraws, misdiagnosis, and improper treatment. Sometimes, these errors may even be fatal (e.g., acute hemolytic reaction after incompatible blood transfusion caused by an error in patient identification).3 It has been observed that diagnostic errors have led to the most prevalent type of malpractice claim in the United States.4 Although errors can arise at any of the three stages, studies show that the pre-analytical phase accounts for 46% to 68.2% of errors observed during the Total Testing Process (Table 1).5 Considerable advances in laboratory instrumentation have significantly reduced the error rate during the analytical phase.6 However, despite the i
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What Is Preanalytical
The Case The Commentary References Tables Topics Resource Type Cases & Commentaries Approach to Improving Safety Checklists Laboratory Result Tracking Improvement Education and Training Safety Target Identification Errors Discontinuities, Gaps, and Hand-Off Problems Setting of Care http://www.mlo-online.com/pre-analytical-errors-their-impact-and-how-to-minimize-them.php Hospitals Clinical Area Pathology & Laboratory Medicine Target Audience Clinical Technologists Nurses Nurse Managers Risk Managers Error Types Noncognitive Errors ("Slips & Lapses") Latent Errors More Share Facebook Twitter Linkedin Email Print The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patient was awakened by the phlebotomist who drew his blood for basic laboratories and type and cross-matching. To https://psnet.ahrq.gov/webmm/case/142 ensure proper patient identification, the hospital had implemented a policy requiring a registered nurse or physician to verify the identity of all patients screened for blood transfusion. In practice, after verification of identity, the nurse or physician was required to initial the patient label on the vial of blood. As it was the change of nursing shift, the bedside nurse for the patient was not available and there were no physicians on the floor at the time. With another floor of patients still to see, the phlebotomist carried the labeled vial of blood out to the nurses' station, and the label was signed by a random nurse. The sample was sent to the laboratory for analysis. Later that morning, a laboratory technician noticed a large and surprising change (compared to the previous day's sample) in the hemoglobin value for a different patient on the same floor. She chose to investigate the discrepancy. Upon review, she realized that the vials of blood for the 54-year-old man had been mislabeled with another patient's label by the phlebotomist. The reason the hemoglobins were so discrepant for this other patient was that today's value was that of the 54-year-old man, the wrong patient. On closer examination, it was determined that all the blood samples had been mislabeled, including the v
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