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CRI Lab Quality Advisor

Correcting Laboratory Report Errors

Published July 1, 2014 11:29 AM by Irwin Rothenberg

By Irwin Rothenberg and Nancy Alers

When a laboratory report must be corrected, and the amended results are sent to the ordering physician, questions may be raised regarding the quality of the laboratory work; the proper operation of the instrumentation involved; the competency of the testing staff, and whether the laboratory director or technical consultant/supervisor were fulfilling their oversight responsibilities.

While the report is the end result of the testing process, the reasons for the release of an erroneous report must be investigated, and the investigation may need to go all the way back to the pre-analytical phase, from test ordering to specimen collection and handling, through the analytical phase (instruments/reagents/staff competency), to the post-analytic phase that includes verification of the LIS (lab information system) for automated and manual results transfer.

Of course, erroneous reports may be due simply to a manual transcription error, initial verbal reports that were misunderstood; or a manual patient mix up. But as simple (though serious) as these are, the reasons these occurred at all still indicates a problem that may involve the core issues of oversight, training, communication and documentation.

There needs to be a formal laboratory policy and procedure for the correction of erroneous laboratory reports (after the correct results are obtained), and for sending amended reports as soon as possible.

These should include the following policies:

  1. Identify who to notify when the error is detected?
  2. Document all steps taken to correct the error;
  3. Provide the ordering physician with the corrected report;
  4. Retain the original report and the corrected report for future reference
  5. Perform a Root Cause Analysis if systemic issues are involved; if serious enough, perform an Incident Management study.
  6. Alternative contact plans if the laboratory is unable to reach the ordering physician or provider in a timely manner.
  7. Inclusion of this event as part of Quality Assessment; include follow up to ensure that the corrective actions taken were effective.

Following these policies and procedures will ensure a consistent quality laboratory response when erroneous reports are issued.

posted by Irwin Rothenberg

6 comments

I think the most expeditious way to see examples of Incident Management studies would be to contact your local hospital or reference laboratory and ask to see how they handle Incident Management.  

One alternative is the labuniversity.org website; Lab Facts #71. This (for purchase item)  provides an overview of Incident Management planning and organization,  and what you need to do to develop an IM plan.

Irwin Rothenberg July 14, 2014 11:30 AM

Here in Puerto Rico,we have private laboratories. We don't need to be necessarily attached to a Hospital or a Clinic. That means we draw samples on ourselves( the MT's ).  I think most of the times,an error may occur in either a misreading of a medical prescription order or the less probable, mismatching of the samples.  But besides it is is very uncomfortable to deal with a lab error report, that procedure may be done as soon as possible to save a patient's life. Every lab and every medical technologist should be involved in the process to get the things well done.

Maribelle Montero, chemistry - general supervisor medical technologist, laboratorio adamar July 13, 2014 10:08 PM
San Juan PR

I'll second the other readers's response, requesting an example of an Incident Management study.  It would be appreciated.  Thank you.

Guy, Education - Lab Specialist, NYC Public H.S. July 12, 2014 10:50 AM
New York NY

Very nice and brief article.

AMJAD KHAN, PATHOLOGY - 8669097284, PATHOLOGY July 11, 2014 12:18 PM
CRANFORD NJ

I would like to see an example of an Incident Management study.  Would anyone care to share?

Cindy, Hematology - Mgr Applications Science, MFG July 11, 2014 8:25 AM
Miami FL

Most of the time its preanalytical errors & 75% errors are before the sample arrive to screening lab from physician/collection centre.

I also agree with postanalytical errors because of less competent scientific skills and  Bio statistical knowledge in Analyst or certifying scientists.

by the its quite intriguing approach for Lab pre/post analytical variations perspective.

Manoj Tyagi July 2, 2014 4:06 PM

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