ECRI Institute PSO study on lab test-related safety events finds most occur outside the laboratory

ECRI Institute PSO recently conducted a Deep Dive analysis of laboratory-related safety events focusing on the impact of errors in the laboratory testing process on clinical decision making. The study found that 96% of the events were associated with processes that actually occurred outside of the laboratory. However, organizations often said that the events they reported originated in the laboratory.

The analysis covers events which occurred from 2011 through May 2013. More than half of the 2,420 reported events were associated with three types of occurrences: mislabeled specimens, specimens with an incomplete or missing label, and missing or delayed results.

ECRI Institute PSO says the responsibility rests with everyone involved in the total testing process:

• The provider who orders a laboratory test to aid in the care of a patient and makes decisions based on test findings
• The individual who collects a specimen
• The transporter who delivers the specimen to the lab
• The laboratorian who processes the test order and records the test results
• The individual who ensures test results are available to ordering personnel.

“We recommend a hierarchy of error-reduction techniques to improve the total testing process and to enhance patient safety,” says Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO.

The Laboratory Safety PSO Deep Dive findings were published in a report available to all ECRI Institute PSO members and its partner PSO members. It reviews strategies for leadership support, standardizing and simplifying some processes, technology solutions, communication and teamwork, staff education, event reporting and analysis, performance improvement, and patient involvement. Read the executive summary of the report.