Open AccessPre-analytical specimen labelling and processing errors in the ICU
Author(s) -
Long Hoai Nguyen,
Sherissa Microys
Publication year - 2022
Publication title -
university of ottawa journal of medicine
Language(s) - English
Resource type - Journals
eISSN - 2292-6518
pISSN - 2292-650X
DOI - 10.18192/uojm.v11is5.5747
Subject(s) - requisition , medical emergency , intensive care unit , medicine , data collection , operations management , medical physics , computer science , emergency medicine , engineering , intensive care medicine , business , statistics , mathematics , marketing
Specimen rejections have been associated with increased in-hospital stay and cost. The majority of errors occur in the pre-analytic phase. Specimen rejection can lead to high rate of recollection, delay in result availability, and high rate of test abandonment. These factors affect patient care and safety.Methods: This study conducted a retrospective review of Patient Safety Learning System (PSLS) reports for the intensive care unit (ICU) at The Ottawa Hospital General Campus (TOH) between 2010 and 2018, and a prospective review using interviews, surveys, and process mapping.Results: From 2098 PSLS reports, 52.6% were related to laboratory specimen collection and processing (pre-analytic phase). Specimen mislabelling with the wrong patient identifier accounted for 9.8% of pre-analytical error reports, while 16.4% of errors were due to non-sufficient quantity (NSQ) of specimen. 12.2 % of pre-analytical error reports involved cytology specimens.Conclusions: Pre-analytical errors are not only costly and resource draining, but may also place a burden on patients. Areas where errors were found include labels and requisitions stored in bedside cabinets, inconsistencies between specimen labels and requisitions, out-dated and difficult to access laboratory manuals, and non-sufficient quantity specimen collection. In the future we hope to start new initiatives to tackle these issues to improve patient safety and hospital efficiencies. This includes the development of a website for the laboratory manual, so that it is more easily accessible and user-friendly. With a new electronic medical record (EMR) system at TOH in 2019, we will explore the affects of pre-analytical processing of specimens.