Bankstown Hospital - Grand Rounds - Further Reading

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Pre-analytical labelling errors

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Gajjar, D., et al. (2024). "Evaluation of Laboratory Performance in Consideration with Pre analytical and Post analytical Quality Indicators." Indian Journal of Clinical Biochemistry 39(2): 264-270: https://doi.org/10.1007/s12291-022-01094-0 PDF available at link

Implementation of Quality indicators (QIs) plays an imperative role in improving the total testing process, as it provides a quantitative basis for evaluating the laboratory performance. Besides monitoring of analytical quality specifications, several lines of experimental and clinical evidence have alluded a pivotal role of extra-analytical phases in improving the quality of laboratory services and therefore a relevance of pre- and post-analytical steps have been speculated on the overall quality in the total testing process and consequently on clinical decision-making. This was a retrospective study designed to evaluate and review different extra-analytical quality indicators in NABL accredited clinical biochemistry laboratory at BJ Medical College and Civil Hospital, Ahmedabad, Gujarat in an endeavour to ameliorate the performance of the laboratory. All Clinical Chemistry Laboratory test requests with their respective samples from January 2018 to December 2021 were included in the study. A total of 1,439,011samples were processed, and were evaluated for seven QIs [(% of number of suitable samples not received; QI-8), (% of number of samples received in inappropriate container; QI-9), (% of number of samples hemolysed; QI-10), (% of number of samples with inadequate sample volume; QI 12) (% of number of samples received mismatched; QI 15), (% of number of samples reported after turnaround time; QI 21) and (% of number of samples with critical values informed; QI 22)] based on defined criteria of Quality Specification given by International Federation of Clinical Chemistry. Total number of preanalytical errors was 53,669 (3.72%). Among the preanalytical errors, inadequate sample volume (2.37% of total samples; 63.49% of total pre-analytical errors) was the most common anomaly followed by Not received samples (24.18%) hemolysis (8.26%) mismatched (3.91%) and 0.14% samples were received in Inappropriate container; manifesting that the error frequency was unacceptable for QI 21 and QI 8, acceptable for QI 10, minimally acceptable for QI 15 and optimum for QI QI 9. Furthermore, there was year-wise progressive decline in error rate of inadequate sample volume, hemolysed sample received and mismatched samples. Total number of post analytical errors were 19,002 (1.32%). TAT outlier and critical values communicated were the two QIs evaluated for this phase and results of both QI were within acceptable limits. Quality indicators serve as a tool to monitor process performance and consequently derived error rates warrant active intervention to improve the laboratory services and patient health care. Dissemination of certified documents, regular staff training and evaluation needs to be conducted.

Grover, G. and B. J. Gadhavi (2024). "Study of Pre-Analytical Errors in Laboratory & Steps to Improve." Saudi Journal of Pathology and Microbiology 9(1): 20-26 https://tinyurl.com/yhp72eyp PDF available at link

Objectives: Pre-analytical errors decisively influence the total laboratory errors and consequently the diagnostic accuracy. The following were the objectives of the study. 1) To detect the percentage of pre-analytical errors in venous specimens in Laboratory. 2) To categorize these pre-analytical errors. 3) To formulate steps of corrective measures to avoid such type of errors. Study Design and Result: Type of Study - Retrospective study. Study period - 12 months (June 2015 to May 2016), documenting the frequency and type of pre-analytical errors. Results: Total number of pre-analytical errors detected in the period of 12 months’ study were 180. Improper timing of specimens, hemolyzed & clotted specimens and improper requests were the major concerns followed by delay in specimen transport. Conclusion: Pre-analytical phase is an important component of Total Laboratory Quality. Pre-analytical errors are not inevitable and can be avoided or minimized with diligent application of quality control, continuing education, effective protocols, and standardized procedures for effective blood collection systems to ensure total Quality patient care.          

Lam, J. C. and D. L. Church (2024). "Preventing laboratory error and improving patient safety – The role of non-laboratory trained healthcare professionals." Clinical Infection in Practice 21: 100345: https://www.sciencedirect.com/science/article/pii/S2590170224000050 REQUEST ARTICLE

In 2023, the World Health Organization estimates that 1 in every 10 patients experiences harm from unsafe care, with 3 million deaths occurring yearly from the same. Over half the cases of patient harm are preventable and resultant from errors. As 70% of medical decision making involves the laboratory, laboratory medicine is looked upon to improve patient safety. However, laboratory errors are not isolated and unpredictable entities, but rather reflective of the overall healthcare system. Laboratory errors often occur outside the laboratory, as medical testing and procedures are performed by individuals with various levels of quality control training. We describe a case of a specimen labeling error which prolonged a patient’s hospitalization, hindered the medical team’s clinical decision making and increased healthcare cost utilization. We review categories of laboratory errors, outline steps to prevent pre-analytical laboratory errors (defined as those that occur before, during or after specimen collection) and describe metrics to measure quality improvement.

Nordin, N., et al. (2024). "Preanalytical errors in clinical laboratory testing at a glance: source and control measures." Cureus 16(3) https://assets.cureus.com/uploads/review_article/pdf/240268/20240330-12401-1r7fzh8.pdf PDF available at link

The accuracy of diagnostic results in clinical laboratory testing is paramount for informed healthcare decisions and effective patient care. While the focus has traditionally been on the analytical phase, attention has shifted towards optimizing the preanalytical phase due to its significant contribution to total laboratory errors. This review highlights preanalytical errors, their sources, and control measures to improve the quality of laboratory testing. Blood sample quality is a critical concern, with factors such as hemolysis, lipemia, and icterus leading to erroneous results. Sources of preanalytical errors encompass inappropriate test requests, patient preparation lapses, and errors during sample collection, handling, and transportation. Mitigating these errors includes harmonization efforts, education and training programs, automated methods for sample quality assessment, and quality monitoring. Collaboration between laboratory personnel and healthcare professionals is crucial for implementing and sustaining these measures to enhance the accuracy and reliability of diagnostic results, ultimately improving patient care.

Tapper, M. A., et al. (2017). "Pre-analytical Errors at the Chemical Pathology Laboratory of a Teaching Hospital." J Clin Diagn Res (2017) 11(8): Bc16-bc18: 0973-709x

https://pmc.ncbi.nlm.nih.gov/articles/PMC5620752/ PDF available at link

INTRODUCTION: The Chemical Pathology Laboratory at the University Hospital of the West Indies (UHWI) processes specimens received from inpatients, the outpatient department and other medical facilities in Jamaica. Specific rejection criteria are used to determine samples unsuitable for analysis. It has been noted that despite efforts to reduce the number of unacceptable samples received in the laboratory, the problem persists. AIM: The study seeks to provide empirical evidence of the inadequacies from which improvements can be formulated. MATERIALS AND METHODS: Errors recorded in the rejection log in the Chemical Pathology laboratory at the University Hospital of the West Indies for the period were assessed. The types and frequency of errors were determined manually. The yearly rejection ratios over a four-year period were evaluated. RESULTS: The most common causes for rejection were unlabelled samples (37%), incorrectly labelled specimens (23%), samples submitted in an inappropriate tube (14%) and incomplete or inaccurately completed requisition forms (14%). The rejection ratio for 2015-2016 was 2.1%. CONCLUSION: The laboratory must initiate programmes directed at improving the preanalytical process in order to ensure patient safety.

Journal of Clinical Pathology

 is a broad scope pathology journal from BMJ and ACP, publishing academic research and practical clinical advice. Available via CIAP.