1. Prof. Dr.Asim Mumtaz Shalamar Medical & Dental College Lahore Effect of Lab Errors on Patient Care

2. Patient & Health care team

3. “To Err is Human”  Building a Safer Health System  Institute of Medicine : 1999  8 th Leading cause of death  44000 – 98000 deaths per year Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human:Building a Safer Health System. Washington, DC: National Academies Press; 2000.

4. 60% to 80% of patient management decisions are based on lab data

5. Prolonged hospital stay Legal Issues Psychological Trauma Financial burden Wrong Diagnosis Wastage of Resources Inappropriate Monitoring Delay in Treatment IMPACT ON PATIENT

6. Laboratory Medicine Every sample is a PATIENT

7. Why Do Lab Errors Occur ? 22Clinicians 10Surgeons 6Paediatricians 12Pathologists

8. Answer “Lab errors mostly occur due to instrument malfunctioning or wrong reporting …”

9. Frequency of Lab Errors 46 – 68% Preanalytical 8 – 17 % Analytical 18 – 47% Postanalytical Errors in medicine and errors in laboratory medicine: What is difference? Blood transfuse. 2010; 8:79-81. Effects of pre analytical errors on quality of laboratory medicine : J Clin Biochem. 2010; 26(1): 46-49.

10. TYPES OF LAB ERRORS Preanalytical AnalyticalPostanalytical LATENT ERRORACTIVE ERROR

11. Latent Errors poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations Active Errors occur at the level of the frontline operator effects are felt almost immediately Latent & Active Errors

12. Examples of Latent Errors in Lab ITLack of instrument interface with LIS Equipment Main chemistry analyzer is overloaded and has no backup. Work Environment Culture of multitasking leads to error-prone environment Policy and Procedures Flaws in Policies and procedures. StaffingChronic understaffing on evening and night shifts leads to high error rate.

13. Preanalytical Variables Voucher – Wrong entry Patient Identification & Preparation Physician Order Missed Sample site selection & preparation Improper venipuncture technique Sample Labeling Inappropriate Container Delayed & Improper transport of Sample to lab

14. Preanalytical Variables Sample Accessioning in Lab Water Bath Temperature variation Centrifugation Wrong Labeling of tubes for analysis Inappropriate Storage of samples

15. Analytical Variables Instrument Error-Malfunctioning Improper Calibration Pipetting error Lack of specificity of method

16. Postanalytical Variables Wrong Entry of Test Results Doctor/Ward Staff not informed about abnormal Results in time Report Signed Without Confirming Result Delayed turn around time (TAT)

17. Frequency of Errors (Six Months Data) Variable Private Hospital Lab Public Sector Hospital Lab Total Samples 127,500 90,000 Total No of Tests Performed 611,081475,000 Total No. of Errors 15302540 Error Rate 1.2 % 2.82 % Preanalytical 70.4% (1078)56.7% (1440) Analytical 12.1% (184)14.9% (380) Postanalytical 17.5% (268)28.4% (720)

18. PhasesIndoorOutdoorTotal Errors Preanalytical 784 (72.7%) 294 (27.2%) 1078 Analytical103 (55.9%)81 (44.02%)184 Postanalytical194 (72.3%)74 (27.6%)268 Frequency of Errors (Six Months Data)

19. Pre Analytical Errors

20. INCREASED ALT AST LDH CK Lipase Mg Creatinine Potassium Phosphate Urea, protein Iron, Ammonia DECREASED Bilirubin Insulin Albumin Effect of Haemolysis on Tests

21. INCREASED Glucose Phosphorus Bilirubin Uric acid Total protein Hb A1c Fructosamine Triglycerides D-dimer ALT/ AST DECREASED Sodium (pseudohyponatremia) HDL cholesterol Ceruloplasmin Prealbumin Transferrin Effect of Lipaemia

22. Patient Name: Sadiq Ahmad Age: 65 yrs Ward: Male Medical Date: 1-3-2011 MR #: 3003455 Tests requested: 1. Blood Sugar Fasting 2. LFTs Patient Name: Mr. Sadiq Age: 62 yrs Ward: Male Medical Date: 1-3-2011 MR #: 3003465 Tests requested: 1. LFTs 2. RFTs 3. Anti HCV 4. HBsAg Effect of Pre Analytical Error : Wrong Identification Public Sector Hospital Lab Interchange of samples

23. Delay in diagnosis Delay in treatment Prolonged hospital stay Wastage of resources Patient inconvenience (Repeat Fasting) Impact on Patient

24. Patient Name: B/O ABC Age: 6 Days Ward: Peads MR #: 2778333 Test Requested: Bilirubin Total 10-2-2011 12-2-2011 13-2-2011 19.5 mg/dl 17 mg/dl 21.5 mg/dl Consequence: Disparity in result  EXCHNAGE TRANSFUSION ? Effect of Analytical Error Example : Public Sector Hospital Lab

25. Patient Name: Iftikhar Age: 35 yrs Ward: Emergency MR #: 2022556 Test Requested: Trop I Result Reported: 4.2 ng/ml Actual Result: 0.42 ng/ml Consequence: Hospital admission  financial burden  Psychological trauma to the patient Effect of Post Analytical Error Example Private Hospital Lab

28. How To Improve

29. Error Identification & Documentation Q Probes Q Track Continuous monitoring Error Identification

30. What we can do? Implementation of systematic error tracking system in daily practice

31. Training of the Nursing Staff Continuous Training & Monitoring of Lab Staff SOP & Sample Rejection Criteria Training & Monitoring

32. Internal Quality Control Program External Quality Control Program Certification & Accreditation Quality Assurance Program

33. Interpretation & Monitoring of Reports Main Analysers – LIS Availability of reports on HIS LIS & HIS

34. How To Gain Strength Policies & Procedures Commitment Communication

35. Thank You