Diagnosis 2018; 5(1): 15–19 Michael A. Noble*, Veronica Restelli, Annemarie Taylor and Douglas Cochrane Laboratory error reporting rates can change significantly with year-over-year examination https://doi.org/10.1515/dx-2017-0043 Received December 12, 2017; accepted January 29, 2018; previously published online February 22, 2018 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 & Learn- ing 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 pre- sented 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 (χ 2 : 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. Keywords: extra analytical; laboratory error; patient safety; quality; reporting system. Introduction Errors in the clinical laboratory put the safety of the patient at risk. Considering laboratory data influences up to 80% of decisions in healthcare and given the large number of laboratory tests performed, even low rates of laboratory errors may reflect a significant number of patients affected [1, 2]. Incidence reporting systems (IRS) have become very useful as a tool to raise awareness of safety issues; they provide an immense opportunity for employee partici- pation and the creation of a culture which emphasizes the identification of quality failure as an opportunity to enhance patient safety [2]. The British Columbia Patient Safety & Learning System (BCPSLS), a province-wide incident reporting system, was launched in 2008 to identify and examine patient safety issues arising within the health authorities of the province of British Columbia (BC), Canada. BCPSLS is a web-based tool that enables the collection, notification, tracking, trending and analysis of patient safety event data. In a previous study [3], we presented the analysis of data compiled by BCPSLS between April 2008 and December 2010 and identified the areas of concern and opportunities for improvement in the laboratory testing process in BC. A second set of data recorded from January 2011 to December 2013 was analyzed and examined in conjunc- tion with the first data set to determine if reporting trends in British Columbia laboratories had remained stable, or had changed in a year-over-year analysis [2]. Materials and methods BCPSLS database BCPSLS is a web-based tool that collects information about patient safety events occurring in healthcare across the province of BC. Reporters can elect to report any event including hazards, near misses and adverse events and classify them using drop-down felds provided by BCPSLS according to a structured taxonomy and clas- sifcation system. There is no process by which events that are not reported can be identifed or tracked. Only patient safety events related to the laboratory testing pro- cess were evaluated in this study. *Corresponding author: Michael A. Noble, MD, FRCPC, University of British Columbia, Program Office for Laboratory Quality Management, Room G409 – 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada, Phone: +1-604-827-1337, E-mail: mnoble@mail.ubc.ca Veronica Restelli: University of British Columbia, Program Office for Laboratory Quality Management, Vancouver, BC, Canada, E-mail: restelli@mail.ubc.ca Annemarie Taylor: British Columbia Patient Safety and Learning System, Vancouver, BC, Canada, E-mail: ataylor@phsa.ca Douglas Cochrane: British Columbia Patient Safety and Learning System, Vancouver, BC, Canada; and British Columbia Patient Safety and Quality Council, Vancouver, BC, Canada, E-mail: dcochrane@cw.bc.ca Brought to you by | University of Sussex Library Authenticated Download Date | 4/4/18 9:51 AM