Voluntary Electronic Reporting of Laboratory Errors

Snydman, Laura K.; Harubin, Beth; Kumar, Sunny; Chen, Jack; Lopez, Robert E.; Salem, Deeb N.

doi:10.1177/1062860611413567

Cited by 21 publications

(10 citation statements)

References 12 publications

(11 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In doing so, we refuted a potential case of infection transmission and identified an important step relevant to future studies of infection transmission in CF patients. Specimen mislabeling is among the most common preanalytic errors identified in clinical laboratories and is a particular risk in environments, such as CF clinics, where the same sample type is collected from multiple patients (50). Our data support the argument that transmission of Achromobacter among CF patients appears to be an uncommon event.…”

Section: Discussionsupporting

confidence: 78%

Prevalence and Outcomes of Achromobacter Species Infections in Adults with Cystic Fibrosis: a North American Cohort Study

et al. 2017

View full text Add to dashboard Cite

Achromobacter species are increasingly being detected in cystic fibrosis (CF) patients, with an unclear epidemiology and impact. We studied a cohort of patients attending a Canadian adult CF clinic who had positive sputum cultures for Achromobacter species in the period from 1984 to 2013. Infection was categorized as transient or persistent (Ն50% positive cultures for 1 year). Those with persistent infection were matched 2:1 with age-, sex-, and time-matched controls without a history of Achromobacter infection, and mixed-effects models were used to assess pulmonary exacerbation (PEx) frequency and lung function decline. Isolates from a biobank were retrospectively assessed, identified to the species level by nrdA sequencing, and genotyped using pulsed-field gel electrophoresis (PFGE). Thirty-four patients (11% of those in our clinic), with a median age of 24 years (interquartile range [IQR], 20.3 to 29.8 years), developed Achromobacter infection. Ten patients (29%) developed persistent infection. Persistence did not denote permanence, as most patients ultimately cleared infection, often after years. Patients were more likely to experience PEx at incident isolation than at prior or subsequent visits (odds ratio [OR], 2.7 [95% confidence interval {CI}, 1.2 to 6.7]; P ϭ 0.03). Following persistent infection, there was no difference in annual lung function decline (Ϫ1.08% [95% CI, Ϫ2.73 to 0.57%] versus Ϫ2.74% [95% CI, Ϫ4.02 to 1.46%]; P ϭ 0.12) or the odds of PEx (OR, 1.21 [95% CI, 0.45 to 3.28]; P ϭ 0.70). Differential virulence among Achromobacter species was not observed, and no cases of transmission occurred. We demonstrated that incident Achromobacter infection was associated with a greater risk of PEx; however, neither transient nor chronic infection was associated with a worsened long-term prognosis. Large, multicenter studies are needed to clarify the clinical impact, natural history, and transmissibility of Achromobacter.

show abstract

Section: Discussionsupporting

confidence: 78%

Prevalence and Outcomes of Achromobacter Species Infections in Adults with Cystic Fibrosis: a North American Cohort Study

et al. 2017

View full text Add to dashboard Cite

show abstract

“…In a study by Syndman et al, after extensive analysis of laboratory reports in 30 healthcare organizations, they found that laboratory events before analysis were the most common (81%) errors. The top three examples of errors were unlabeled specimens (18.7%), wrongly labeled specimens (16.3%), and improper collection (13.2%) [ 20 ]. In the study of Makary et al, in the evaluation of 21,351 surgical specimens, 11 cases (0.05%) of inappropriate label errors were discovered, which led to assigning the specimen to the wrong patient [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of errors related to surgical pathology specimens of different hospital departments with a patient safety approach: a case study in Iran

et al. 2023

View full text Add to dashboard Cite

Background Most surgical specimen errors occur in the pre-analysis stage, which can be prevented. This study aims to identify errors related to surgical pathology specimens in one of the most comprehensive healthcare centers in Northeast Iran. Methods The present study is descriptive and analytical research conducted cross-sectionally in 2021 at Ghaem healthcare center in the Mashhad University of Medical Sciences on the basis of a census sampling. We used a standard checklist to collect information. Professors and pathologists evaluated the validity and reliability of the checklist using Cronbach’s alpha calculation method of 0.89. We analyzed the results using statistical indices, SPSS 21 software, and the chi-square test. Results Out of 5617 pathology specimens studied, we detected 646 errors. The highest number of errors is the mismatch of the specimen with the label (219 cases; 3.9%) and the non-compliance of the patient’s profile in the specimen sent with the label (129 cases; 2.3%), and the lowest errors are the inappropriate volume of the fixator(24 cases; 0.4%), and they accounted for insufficient sample size (25 cases; 0.4%). Based on Fisher’s exact test results, there was a significant difference between the proportion of errors in different departments and months. Conclusion Considering the frequency of labeling errors in the stage before the analysis in the pathology department, the use of barcode imprinted in specimen containers, the removal of the paper request for pathology, the use of radio frequency chip technology, the use of the rechecking system and improving communication in different departments can be effective in reducing these errors.

show abstract

“…Laboratory information systems (LISs) are HISs that can be used to order tests, process samples, receive results, and create and communicate reports (8). LISs can improve laboratory processes and documentation accuracy of laboratory test results.…”

Section: Introductionmentioning

confidence: 99%

“…LISs can improve laboratory processes and documentation accuracy of laboratory test results. Nevertheless, research has shown that the use of LISs can have major errors (8)(9)(10). Laboratory errors can lead to wrong diagnosis, inappropriate care, delayed treatment, poor clinical research, increased costs, and endanger patients' lives (9).…”

Section: Introductionmentioning

confidence: 99%

Compliance with design principles: a case study of a widely used laboratory information system

Agharezaei¹,

Khajouei²,

Ahmadian³

et al. 2020

East Mediterr Health J.

View full text Add to dashboard Cite

Background: Laboratory information systems are widely used health information systems that have the potential to improve health care quality. Despite their benefits, many studies have indicated problems with user interaction with these systems due to poor interface design. Aims: To evaluate the usability of a laboratory information system. Methods: In this descriptive, cross-sectional study, we used heuristic evaluation to examine the user interface design of a laboratory information system in an academic hospital affiliated with Kerman University of Medical Sciences in 2017. This system is also used in 59 other Iranian hospitals .We investigated the usability of different parts of the usability of a laboratory information system (outpatient admission, inpatient admission, sample collection, and test result reporting). Data were collected using a standard form based on the heuristic evaluation method, and categorized based on their severity and violated heuristics. The content validity was confirmed by 3 medical informatics specialists. Results: We identified 162 usability problems. In terms of the heuristics, the highest number of problems concerned flexibility and efficiency of use (n = 32, 19.75%) and the lowest concerned help users recognize, diagnose, and recover from errors (n = 2, 1.23%). In terms of different modules of the system, the highest number of problems (n = 51, 31.48%) concerned outpatient admission and the lowest (n = 29, 17.9%) concerned sample collection. In terms of severity, 45.06% of the problems were rated as major. Conclusions: Despite widespread use of laboratory information systems, their user interface design has usability problems that diminish the quality of user interaction with these systems and may affect the quality of health care. Consideration of standards and principles for user interface design, such as the heuristics used in this study, could improve system usability.

show abstract

Voluntary Electronic Reporting of Laboratory Errors

Cited by 21 publications

References 12 publications

Prevalence and Outcomes of Achromobacter Species Infections in Adults with Cystic Fibrosis: a North American Cohort Study

Prevalence and Outcomes of Achromobacter Species Infections in Adults with Cystic Fibrosis: a North American Cohort Study

Evaluation of errors related to surgical pathology specimens of different hospital departments with a patient safety approach: a case study in Iran

Compliance with design principles: a case study of a widely used laboratory information system

Contact Info

Product

Resources

About