Frequently Occurring Error in Laboratory

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Diagnosis or evaluation Medical decision-making Treatment Medication Procedural complications Faulty communication Inadequate supervision

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Frequently Occurring Error in Laboratory Practices leading to wrong diagnosis : 

Frequently Occurring Error in Laboratory Practices leading to wrong diagnosis Dr.Kedar Karki

Types of medical mistakes. : 

Types of medical mistakes. ERROR Diagnosis or evaluation Medical decision-making Treatment Medication Procedural complications Faulty communication Inadequate supervision EXAMPLE Missed diagnosis Inappropriate or premature discharge Waiting when treatment is indicated Incorrect dosage Faulty technique Failure to convey information during sign-out Failure to review treatment plan

Common Causes of Medical Mistakes : 

Common Causes of Medical Mistakes Ignorance Inexperience Faulty judgment Hesitation Fatigue Job overload Breaks in concentration Faulty communication Failure to monitor closely System flaws

S I M P L E T R U T H S A B O U T E R R O R S I N M E D I C I N E : 

S I M P L E T R U T H S A B O U T E R R O R S I N M E D I C I N E 1. Errors will happen. Since no human is infallible, errors are bound to happen, and this includes physicians and their staffs working in the delivery of health care services. 2. Since errors can be expected, systems must be designed to prevent and absorb them. 3. Errors are not synonymous with negligence. 4. Creating a culture supportive of errors reporting is the starting point in reducing future medical errors.

Types of error : 

Types of error Laboratory mistakes occur mainly at three levels: pre-analytic, analytic and post-analytic.

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The testing cycle.

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Quality efforts have traditionally focused only on the analytic phase

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The opportunity for improvement.

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A patient's test sample or paperwork is mixed up with that of another patient Specimens or samples are taken incorrectly Images or test samples are mishandled or lost Results are misinterpreted Patient identification errors are made

Pathology laboratory mistakes: : 

Pathology laboratory mistakes: Errors in labeling samples: mix-ups in patient samples Cross-contamination during testing Inherent known risks in various tests (false positives, false negatives) Limitations of certain tests for certain patients Human error in examining visual slides (e.g. cell biopsy, Pap smears)

Factors That Can Affect the Analytical Result : 

Factors That Can Affect the Analytical Result Some type of processing is required for most biological samples immediately following their collection from an animal or human subject. Most commonly this involves collection of a venous blood sample followed by centrifugation to harvest plasma or serum to be frozen for later analysis.

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procedure, and conditions such as temperature, centrifugation time and force, and maximum time from sampling to freezing the sample are specified in study documentation.

Sample Stability and Storage Conditions : 

Sample Stability and Storage Conditions Adequate documentation is also needed to track the location of the samples throughout their storage, from receipt until disposal, and to document the temperature in the storage freezers while the samples are stored.

Sample Transport : 

Sample Transport samples are usually shipped frozen in insulated containers with dry ice. The main concern is ensuring that the shipment is still frozen upon arrival. Data loggers can be included within shipment packages to monitor temperature; however, these are not generally used, particularly as shipments are usually packed with sufficient dry ice to last for a significantly greater period than the anticipated shipment time. It is important that the sample condition be accurately recorded on receipt to document that samples were received still frozen and in good condition.

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errors can occur when labels are ambiguous, do not match the protocol or case report forms, or have been altered or incorrectly completed.

Most Errors are associated with : 

Most Errors are associated with Misidentification of patient. Collecting ,storing specimens incorrectly. Technical imprecision and inaccuracy. Reader variability. Adverse laboratory working conditions. Misinterpreting results.

Misidentification of patient. : 

Misidentification of patient. Incomplete identification data. Language difficulties. Specimen container incorrectly labelled. No reliable check-in system in lab.

Collecting ,storing specimens incorrectly. : 

Collecting ,storing specimens incorrectly. A specimen is not correct,inadequate,collected at incorrect time. Incorrect collection technique A wet needle and syringe used to collect blood specimen resulting in haemolysis of red blood cell.

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Container not cleaned,dried,not containing correct anticoagulant,preservative,not sterile. Loose container cap,resulting loss,evaporation,contamination of samples. Not stored properly has been left for too long period in store or in transite.

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Blood film samples not protected from insect, dust or direct sunlight. No inspection of specimens when they reach the laboratory.

Technical imprecision and inaccuracy. : 

Technical imprecision and inaccuracy. Errors in imprecision: result differ from correct result by varying amount. Errors in inaccuracy: -Errors of bias

Errors in imprecision: : 

Errors in imprecision: Incorrect and variable pippeting. Dispensing technique poor. Unclear marking.

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Inadequate mixing of samples with reagent. Samples not incubated. Glassware or plastic ware not cleaned and dry. Equipment malfunction Laboratory staff not trained for correct use and maintenance of equipment

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Incomplete removal of interfering substance,RBC IN SERUM ASSAY. Thick thin smear. Incorrect reporting of Microscopical preparation.

Common cause of inaccuracy : 

Common cause of inaccuracy Incorrect/indifferent calibration of test method. Using automatic pipetter set at incorrect volume. Wrongly prepared control sera. Incubating samples on wrong temperature. Use of unsatisfactory reagents.

Mistake made by laboratory staff due to adverse working condition. : 

Mistake made by laboratory staff due to adverse working condition. Workload too high or low. The laboratory too small poorly lit. not sufficiently ventilated or screened from sunlight. Lack of motivation encouragement. Too many urgent test.

Errors must be prevented to the fullest extent possible. : 

Errors must be prevented to the fullest extent possible. Error prevention measures include: Reduced reliance on memory. Improved information access. Error-proofing systems. Standardization. Training on error identification and prevention. Examples in medical practice: Checklists, flow sheets, Handheld computer, electronic medical records. Office formularies, guidelines synthesis. Staff inservices.

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