Diagnosis 2017; 4(2): 79–86 Veronica Restelli, Annemarie Taylor, Douglas Cochrane and Michael A. Noble* Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system DOI 10.1515/dx-2017-0013 Received March 15, 2017; accepted May 8, 2017; previously published online May 23, 2017 Abstract Background: This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System. Methods: The reports were collected from 75 hospital- based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported. Results: Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences. Conclusions: It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events. Keywords: laboratory error; patient safety; post-analyti- cal; pre-analytical; 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 health care and given the large number of laboratory tests performed, even low rates of laboratory error may reflect a significant number of patients affected [1, 2]. The recognition of quality failures in the total testing process is important as it helps identify weaknesses in the system [2]. If incidents are not systematically recognized and analyzed, any quality improvement or reduction in risk of reoccurrence is unlikely [1]. Incident report systems (IRS) collect information about safety events including errors that were caught and resolved before they reached the patient all the way to those that resulted in patient’s harm. IRS have been associated with increased awareness about patient safety and improved safety as they allow quality improvement through the prioritization of corrective actions. 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 authori- ties 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. These tools help BC health authorities to focus their efforts on reducing and mitigating adverse events. In this study, we present the analysis of data com- piled by BCPSLS between April 2008 and December 2010 to identify the areas of concern and opportunities for improvement in the laboratory testing process in BC. 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. In *Corresponding author: Michael A. Noble, MD, FRCPC, University of British Columbia, Program Office for Laboratory Quality Management, Room G409 – 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5, 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 Annemarie Taylor: British Columbia Patient Safety and Learning System, Vancouver, BC, Canada Douglas Cochrane: British Columbia Patient Safety and Learning System, Vancouver, BC, Canada; and British Columbia Patient Safety and Quality Council, Vancouver, BC, Canada Brought to you by | UCL - University College London Authenticated Download Date | 1/11/18 5:48 PM