| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Minireview |
1 Università Vita-Salute San Raffaele, Cattedra di Biochimica Clinica, Via Olgettina 58, 20132 Milan, Italy.
2 Istituto Scientifico H. S. Raffaele, Servizio Integrato di Medicina di Laboratorio, Via Olgettina 60, 20132 Milan, Italy.
3 Servizio di Medicina di Laboratorio, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35100 Padova, Italy.
aAuthor for correspondence. Fax 39-02-2643-2640; e-mail bonini.pierangelo{at}hsr.it.
Abstract
Background: The problem of medical errors has recently received a great deal of attention, which will probably increase. In this minireview, we focus on this issue in the fields of laboratory medicine and blood transfusion.
Methods: We conducted several MEDLINE queries and searched the literature by hand. Searches were limited to the last 8 years to identify results that were not biased by obsolete technology. In addition, data on the frequency and type of preanalytical errors in our institution were collected.
Results: Our search revealed large heterogeneity in study designs and quality on this topic as well as relatively few available data and the lack of a shared definition of "laboratory error" (also referred to as "blunder", "mistake", "problem", or "defect"). Despite these limitations, there was considerable concordance on the distribution of errors throughout the laboratory working process: most occurred in the pre- or postanalytical phases, whereas a minority (13–32% according to the studies) occurred in the analytical portion. The reported frequency of errors was related to how they were identified: when a careful process analysis was performed, substantially more errors were discovered than when studies relied on complaints or report of near accidents.
Conclusions: The large heterogeneity of literature on laboratory errors together with the prevalence of evidence that most errors occur in the preanalytical phase suggest the implementation of a more rigorous methodology for error detection and classification and the adoption of proper technologies for error reduction. Clinical audits should be used as a tool to detect errors caused by organizational problems outside the laboratory.
The following articles in journals at HighWire Press have cited this article:
|
|
 |
|
  A.-S. Schrohl, S. Wurtz, E. Kohn, R. E. Banks, H. J. Nielsen, F. C. G. J. Sweep, and N. Brunner Banking of Biological Fluids for Studies of Disease-associated Protein Biomarkers Mol. Cell. Proteomics, October 1, 2008; 7(10): 2061 - 2066. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Nutt, A. E Zemlin, and R. T Erasmus Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa Ann Clin Biochem, September 1, 2008; 45(5): 463 - 466. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. M. Sturgeon, B. R. Hoffman, D. W. Chan, S.-L. Ch'ng, E. Hammond, D. F. Hayes, L. A. Liotta, E. F. Petricoin, M. Schmitt, O. J. Semmes, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Clinical Practice: Quality Requirements Clin. Chem., August 1, 2008; 54(8): e1 - e10. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. R. Pompano, H.-W. Li, and R. F. Ismagilov Rate of Mixing Controls Rate and Outcome of Autocatalytic Processes: Theory and Microfluidic Experiments with Chemical Reactions and Blood Coagulation Biophys. J., August 1, 2008; 95(3): 1531 - 1543. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J O'Kane, P L M. Lynch, and N. McGowan The development of a system for the reporting, classification and grading of quality failures in the clinical biochemistry laboratory Ann Clin Biochem, March 1, 2008; 45(2): 129 - 134. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Carraro and M. Plebani Errors in a Stat Laboratory: Types and Frequencies 10 Years Later Clin. Chem., July 1, 2007; 53(7): 1338 - 1342. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. M. Reisfield, E. Salazar, and R. L. Bertholf Rational Use and Interpretation of Urine Drug Testing in Chronic Opioid Therapy Ann. Clin. Lab. Sci., January 1, 2007; 37(4): 301 - 314. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. G. Crone, M. B. Muraski, J. D. Skeel, L. Love-Gregory, J. H. Ladenson, and A. M. Gronowski Between a Rock and a Hard Place: Disclosing Medical Errors Clin. Chem., September 1, 2006; 52(9): 1809 - 1814. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Lippi, A. Bassi, G. Brocco, M. Montagnana, G. L. Salvagno, and G. C. Guidi Preanalytic error tracking in a laboratory medicine department: results of a 1-year experience. Clin. Chem., July 1, 2006; 52(7): 1442 - 1443. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Yuan, M. L. Astion, J. Schapiro, and A. P. Limaye Clinical Impact Associated with Corrected Results in Clinical Microbiology Testing J. Clin. Microbiol., May 1, 2005; 43(5): 2188 - 2193. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Rej Clinical Chemistry through Clinical Chemistry: A Journal Timeline Clin. Chem., December 1, 2004; 50(12): 2415 - 2458. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Dix and J. H Ladenson Priority In Clinical Chemistry: Does It Match International Public Health Need? * Comment on Dix Clin. Chem., October 1, 2003; 49(10): 1712 - 1714. [Full Text] [PDF]
|
|
|
|
|
|
E. J. Giltay, J. M. Geleijnse, E. G. Schouten, M. B. Katan, and D. Kromhout High Stability of Markers of Cardiovascular Risk in Blood Samples Clin. Chem., April 1, 2003; 49(4): 652 - 655. [Full Text] [PDF]
|
|
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
