Michael A Noble1, Veronica Restelli1, Annemarie Taylor2, Douglas Cochrane2,3. 1. University of British Columbia, Program Office for Laboratory Quality Management, Vancouver, BC, Canada. 2. British Columbia Patient Safety and Learning System, Vancouver, BC, Canada. 3. British Columbia Patient Safety and Quality Council, Vancouver, BC, Canada.
Abstract
BACKGROUND: Incident reporting systems are useful tools to raise awareness of patient safety issues associated with healthcare error, including errors associated with the medical laboratory. METHODS: Previously, we presented the analysis of data compiled by the British Columbia Patient Safety & Learning System over a 3-year period. A second comparable set was collected and analyzed to determine if reported error rates would tend to remain stable or change. RESULTS: Compared to the original set, the second set presented changes that were both materially and statistically significant. Overall, the total number of reports increased by 297% with substantial changes between the pre-examination, examination and post-examination phases (χ2: 993.925, DF=20; p<0.00001). While the rate of change for pre-examination (clerical and collection) errors were not significantly different than the total year results, the rate of change for reporting examination errors rose by 998%. While the exact reason for dramatic change is not clear, possible explanations are provided. CONCLUSIONS: Longitudinal error rate tracking is a useful approach to monitor for laboratory quality improvement.
BACKGROUND: Incident reporting systems are useful tools to raise awareness of patient safety issues associated with healthcare error, including errors associated with the medical laboratory. METHODS: Previously, we presented the analysis of data compiled by the British ColumbiaPatient Safety & Learning System over a 3-year period. A second comparable set was collected and analyzed to determine if reported error rates would tend to remain stable or change. RESULTS: Compared to the original set, the second set presented changes that were both materially and statistically significant. Overall, the total number of reports increased by 297% with substantial changes between the pre-examination, examination and post-examination phases (χ2: 993.925, DF=20; p<0.00001). While the rate of change for pre-examination (clerical and collection) errors were not significantly different than the total year results, the rate of change for reporting examination errors rose by 998%. While the exact reason for dramatic change is not clear, possible explanations are provided. CONCLUSIONS:Longitudinal error rate tracking is a useful approach to monitor for laboratory quality improvement.
Entities:
Keywords:
extra analytical; laboratory error; patient safety; quality; reporting system