Risk management in the preanalytical phase of laboratory testing

Clinical Chemistry and Laboratory Medicine

Volumn 45, Issue 6, 2007, Pages 720-727

  Lippi, Giuseppe ^a,b   Guidi, Gian Cesare ^a  

^a UNIVERSITY OF VERONA   (Italy)

^b UNIVERSITY HOSPITAL OF VERONA   (Italy)

Author keywords

Errors; Laboratory testing; Preanalytical phase; Quality; Risk management

Indexed keywords

ACCREDITATION; ANALYTICAL ERROR; BLOOD; BLOOD CLOTTING; CLINICAL LABORATORY; EDUCATION; EVIDENCE BASED MEDICINE; HEALTH CARE PERSONNEL; HEMOLYSIS; HOSPITAL PATIENT; HUMAN; LABORATORY TEST; LITERATURE; MEDICAL ERROR; OUTPATIENT; PATIENT CARE; PREVALENCE; PRIORITY JOURNAL; REVIEW; RISK MANAGEMENT; STATISTICAL SIGNIFICANCE; TRAINING;

DIAGNOSTIC ERRORS; HUMANS; LABORATORY TECHNIQUES AND PROCEDURES; RISK MANAGEMENT;

EID: 34250741964     PISSN: 14346621     EISSN: 14374331     Source Type: Journal    
DOI: 10.1515/CCLM.2007.167     Document Type: Review

References (45)

1. Dean B. Learning from prescribing errors. Qual Saf Health Care 2002;11;258-60.
2. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To err is human" report and the patient safety literature. Qual Saf Health Care 2006;15:174-8.
3. Solomon RC. Ethical issues in medical malpractice. Emerg Med Clin North Am 2006;24:733-47.
4. Chiozza ML, Plebani M. Clinical Governance: from clinical risk management to continuous quality improvement. Clin Chem Lab Med 2006;44:694-8.
5. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. J Am Med Assoc 2003;290:1868-74.
6. Crone KG, Muraski MB, Skeel JD, Love-Gregory L, Ladenson JH, Gronowski AM. Between a rock and a hard place: disclosing medical errors. Clin Chem 2006;52:1809-14.
7. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003;20:231-6.
8. Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med 2005;129:1252-61.
9. Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002;48:691-8.
10. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med 2004;24:979-96.
11. Hollensead SC, Lockwood WB, Elin RJ. Errors in pathology and laboratory medicine: consequences and prevention. J Surg Oncol 2004;88:161-81.
12. Kalra J. Medical errors: impact on clinical laboratories and other critical areas. Clin Biochem 2004;37:1052-62.
13. Lippi G, Guidi GC, Mattiuzzi C, Plebani M. Preanalytical variability: the dark side of the moon in laboratory testing. Clin Chem Lab Med 2006;44:358-65.
14. Plebani M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med 2006;44:750-9.
15. Plebani M, Carraro P. Mistakes in a stat laboratory: types and frequency. Clin Chem 1997;43:1348-51.
16. Wiwanitkit V. Types and frequency of preanalytical mistakes in the first Thai ISO 9002:1994 certified clinical laboratory, a 6-month monitoring. BMC Clin Pathol 2001;1:5.
17. Dale JC, Novis DA. Outpatient phlebotomy success and reasons for specimen rejection. Arch Pathol Lab Med 2002;126:416-9.
18. Romero A, Munoz M, Ramos JR, Campos A, Ramirez G. Identification of preanalytical mistakes in the stat section of the clinical laboratory. Clin Chem Lab Med 2005;43:974-5.
19. Plebani M, Ceriotti F, Messeri G, Ottomano C, Pansini N, Bonini P. Laboratory network of excellence: enhancing patient safety and service effectiveness. Clin Chem Lab Med 2006;44:150-60.
20. Siddiqui S. Laboratory errors as judged by test request slips and test reports. J Coll Physicians Surg Pak 2006;16:136-8.
21. Lippi G, Bassi A, Brocco G, Montagnana M, Salvagno GL, Guidi GC. Preanalytic error tracking in a laboratory medicine department: results of a 1-year experience. Clin Chem 2006;52:1442-3.
22. Kalra J. Medical errors: impact on clinical laboratories and other critical areas. Clin Biochem 2004;37:1052-62.
23. Sommerville I. Integrated requirements engineering. IEEE Software 2005;22:16-23.
24. Reason J. Human error: models and management. Br Med J 2000;320:768-70.
25. Sawyer P, Sommerville I. Capturing the benefits of requirements engineering. IEEE Software 1999;16:78-85.
26. Sciacovelli L, Secchiero S, Zardo L, Zaninotto M, Plebani M. External Quality Assessment: an effective tool for Clinical Governance in laboratory medicine. Clin Chem Lab Med 2006;44:740-9.
27. Lippi G, Guidi GC. Preanalytic indicators of laboratory performances and quality improvement of laboratory testing. Clin Lab 2006;52:457-62.
28. Lippi G, Salvagno GL, Montagnana M, Franchini M, Guidi GC. Phlebotomy issues and quality improvement in results of laboratory testing. Clin Lab 2006;52:217-30.
29. Vermeer HJ, Thomassen E, de Jonge N. Automated processing of serum indices used for interference detection by the laboratory information system. Clin Chem 2005;51:244-7.
30. Stull TM, Hearn TL, Hancock JS, Handsfield JH, Collins CL. Variation in proficiency testing performance by testing site. J Am Med Assoc 1998;279:465.
31. Hales BM, Pronovost PJ. The checklist - a tool for error management and performance improvement. J Crit Care 2006;21:231-5.
32. Van der Weijden T, van Bokhoven MA, Dinant GJ, van Hasselt CM, Grol RP. Understanding laboratory testing in diagnostic uncertainty: a qualitative study in general practice. Br J Gen Pract 2002;52:974-80.
33. Stankovic AK, Smith S. Elevated serum potassium values: the role of preanalytic variables. Am J Clin Pathol 2004;121(Suppl):S105-12.
34. Hira K, Aoki N, Fukui T. Pseudohyperkalaemia at commercial laboratories in Japan: a questionnaire survey. Ann Clin Biochem 2004;41:155-6.
35. Elston DM. Laboratory results that should be ignored. MedGenMed 2006;8:9.
36. Foubister V. Bench press: the technologist/technicians shortfall is putting the squeeze on laboratories nationwide. CAP Today 2000:84.
37. Nutting PA, Main DS, Fischer PM, Stull TM, Pontious M, Seifert M Jr, et al. Problems in laboratory testing in primary care. J Am Med Assoc 1996;275:638.
38. American Society for Clinical Pathology. Quality laboratory practice and its role in patient safety: The American Society for Clinical Pathology Policy Statement (Policy Number 06-01). Available at: http://www.medscape.com/ viewarticle/546192. Accessed November 24, 2006.
39. Trenti T. Evidence-based laboratory medicine as a tool for continuous professional improvement. Clin Chim Acta 2003;333:155-67.
40. Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med 2006;130:1662-8.
41. Waise A, Plebani M. Which surrogate marker can be used to assess the effectiveness of the laboratory and its contribution to clinical outcome? Ann Clin Biochem 2001;38:589-95.
42. Plebani M. Towards quality specifications in extra-analytical phases of laboratory activity. Clin Chem Lab Med 2004;42:576-7.
43. Conan Doyle A. The sign of four. Lippincott's Magazine 1890;February.
44. Plebani M. Charting the course of medical laboratories in a changing environment. Clin Chim Acta 2002;319:87-100.
45. Guidi GC, Lippi G. Laboratory medicine in the 2000s: programmed death or rebirth? Clin Chem Lab Med 2006;44:913-7.