(P)Laboratory Diagnostic Errors Flashcards
depend heavily on laboratory test results, yet errors can occur at any at any stage
Medical Diagnoses
TOF
Knowing the causes
and types of errors can help reduce their occurrence.
T
Occurs before testing
Pre-analytic errors
Occur during testing
Analytical Errors
Occur after tasting
kabaklaan (Post-Analytical Errors)
Accounts for 46-68% laboratory errors
Pre-analytic errors
Accounts for 7-13% laboratory errors
Analytic errors
Accounts for 18-47% lab errors
Post-analytic errors
ranks second (pre ang first)
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
inaccurate patient identification;
ordering the wrong test
Pre-Analytical Errors
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
improper specimen collection & transportation, and receipt handling and preparation of sample
Pre-Analytical Errors
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
instrumentation problems and
human errors during testing
Analytical Errors
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
inappropriate samples e.g. incorrect blood tubes for particular analyses, calibration errors, instrument malfunctions, the presence of interfering substances, and the failure to verify the results
Analytical Errors
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
result interpretation and communication errors reports being sent to the wrong health care provider
Post-Analytical Errors
CAUSES OF LABORATORY DIAGNOSTIC ERRORS
- long turnaround times,
- missing reports,
- improper interpretation of test results by healthcare providers
Post-Analytical Errors
In one particular study that was done in hematology and the chemical pathology section or the chemistry section, what was the number 1 pre-analytic error observed?
unlabeled sample
List other errors observed in the study done in hematology and chemical pathology apart from unlabeled samples
- clotted sample
- samples that are diluted
- wrong medical record number
- samples that are
hemolyzed - incorrect tube/ QNS
- wrong anticoagulant to blood ratio
In the article presented, how many diagnostic errors are recorded each year?
18 million/yr
slay purr
TOF
Diagnostic errors are not a major concern and shouldn’t be addressed
F
sis?
COMMON ERRORS IN PRE-ANALYTICAL PHASE
E-request, Label (Bar Coding) All
Sample
match the preventive act with the error
Missing sample and
or test result
COMMON ERRORS IN PRE-ANALYTICAL PHASE
- Proper ID of patient
- Use Patient or Hospital Name Tag
- Ask for Assistance from nurse or Patient’s Watcher
match the preventive act with the error
Wrong or missing
identification of
patient
COMMON ERRORS IN PRE-ANALYTICAL PHASE
Monitor blood transfusion
match the preventive act with the error
Contamination from
infusion route
COMMON ERRORS IN PRE-ANALYTICAL PHASE
- Trained phlebotomist
- Clean and dry test tube and use
disposable syringe
match the preventive act with the error
Hemolyzed, Clotted,
and insufficient
sample
COMMON ERRORS IN PRE-ANALYTICAL PHASE
- Use the Right test tube with appropriate anticoagulant with the right test requested
- Use a sterile container if required
match the preventive act with the error
Inappropriate
Containers
COMMON ERRORS IN PRE-ANALYTICAL PHASE
- Check the vacuum of the test tube
- Fill-in the test-tube with blood according to the required amount
match the preventive act with the error
Inappropriate blood
to anticoagulant
ratio
COMMON ERRORS IN PRE-ANALYTICAL PHASE
Appropriate handling and storage
of sample
match the preventive act with the error
Inappropriate
transport and
storage conditions
Actual performance of the laboratory test
ANALYTICAL PHASE
Validation of the result and the release of the result for review.
ANALYTICAL PHASE
TOF
Advances in pre-analytical techniques, laboratory
instrumentation, and automation have improved analytical quality resulting in a significant increase in error rates
F
* advances in analytical techniques
* significant decrease in error rates
ANALYTICAL ERRORS
errors such as incorrect
manual pipetting
Technologist Errors
ANALYTICAL ERRORS
Important for accurate results. Failure to do this activity properly can lead to inaccuracies.
Instrument
Calibration
ANALYTICAL ERRORS
Proper quality control of reagents is essential to ensure accurate lab results.
Reagent Quality
Control
COMMON ERRORS IN ANALYTICAL PHASE
Familiarize
Sample Lost
Sample Mix up
Equipment Failure
Analytical Error
Invalid Result and No delta check done
PRE/ANA/POST?
Sample Lost
Ana
PRE/ANA/POST?
Sample Mix up
Ana
PRE/ANA/POST?
Equipment failure
Ana
PRE/ANA/POST?
Invalid Result and No delta check done
Ana
The final phase of the total testing process
POST-ANALYTICAL PHASE
Involves evaluation of laboratory test results
POST-ANALYTICAL PHASE
- Release of test results in a timely manner to appropriate
individuals - Particularly critical results
Post Analytical Phase
Modification, annotations, or revocation of results as necessary to support clinical decision-making
POST-ANALYTICAL PHASE
PRE/ANA/POST?
Test Result lost
POST
PRE/ANA/POST?
Turnaround time
POST
PRE/ANA/POST?
Transcription error
Post
PRE/ANA/POST?
Incorrect interpretation
Post
STARTEGIES FOR ERROR PREVENTION
includes effective internal audits, which helps detect and prevent errors.
Implementing Quality Control Measure
STARTEGIES FOR ERROR PREVENTION
increases staff knowledge and abilities, reducing the risk of errors.
Regular Training
and Competency
Assessments
STARTEGIES FOR ERROR PREVENTION
Enhancing the communication of laboratory results to healthcare providers can improve patient care and safety
Improves
Communication
within the
Healthcare Team
STARTEGIES FOR ERROR PREVENTION
can help prevent errors and increase
efficiency in the lab.
Using Advance
Technologies
TOF
Involvement of regulatory agencies in laboratory operations limits compliance with quality standards
F (can help ensure compliance)
QUALITY ASSURANCE AND ACCREDITATION
What are the accreditation programs that can enable laboratories to establish and maintain quality systems.
CLIA and ISO 15189
IMPORTANCE OF QUALITY CONTROL AND STANDARIZATION IN LABORATORIES
A crucial component of lab work to
ensure accurate results.
QC
IMPORTANCE OF QUALITY CONTROL AND STANDARIZATION IN LABORATORIES
Discourages variability between different laboratories and ensures that results can be compared.
Standardization
IMPORTANCE OF QUALITY CONTROL AND STANDARIZATION IN LABORATORIES
International organizations have taken significant steps to promote quality control and standardization in
laboratories
National
and
Global Initiatives
IMPORTANCE OF QUALITY CONTROL AND STANDARIZATION IN LABORATORIES
What are the significant steps undertaken by int’l organization to promote QC and standardization in labs?
establishing standard operating procedures (SOPs) and reference materials.
FUTURE OF DIAGNOSING WITH THE IMPLEMENTATION TECHNOLOGY
Technology can more accurately and efficiently analyze large amounts of data and images.
Improved accuracy
and efficiency
FUTURE OF DIAGNOSING WITH THE IMPLEMENTATION TECHNOLOGY
Objective and consistent results of
the operator or location
Reduced Variability
FUTURE OF DIAGNOSING WITH THE IMPLEMENTATION TECHNOLOGY
An early study has proposed that theimplementation of AI technology in pathology could reduce error rates
down to 0.5%.
Reduced diagnostic
errors
gz dis last card if u concrete sequential learner like me and nath.
OA D PA TAPOS CHECK MO LAST TABLE SA SENIOR TRANSES MWAH
CONSEQUENCES OF DIAGNOSTIC ERRORS
Diagnostics errors can lead to inappropriate treatment, delayed
diagnosis, and unnecessary procedures.
Patient Harm
CONSEQUENCES OF DIAGNOSTIC ERRORS
Diagnostic errors result in the misuse of healthcare resources, resources, including unnecessary medical tests and procedures.
Financial cost
CONSEQUENCES OF DIAGNOSTIC ERRORS
Diagnostic errors can leave patients feeling dismissed or let down.
Psychological Impact