Pre Analytic Phase of Testing

Novis DA. Detecting and preventing the occurrence of errors in the practices of Laboratory Medicine and Anatomic Pathology: fifteen years experience with the College of American Pathologists Q- PROBES and Q-TRACKS programs. Clin Lab Med. 2004; 24:965-978.

PRE ANALYTIC PHASE OF TESTING

Reference / No. of institutions / Aggregate observations
(x 103) / Quality Indicator / Benchmark Data / Practice variables associated with benchmarks
Aggregate (%) / Institutional Percentiles(%)
10 / M / 90
Errors in test ordering: Laboratory Medicine
7 / 577 / 250 tests / # tests performed without written orders /total tests performed / 2.5 / 7.1 / 1.9 / 0 / Higher #:No policies requiring staff to verify order accuracy
Use of preprinted "checkoff" order forms
# written orders without tests performed /total tests performed / 2.8 / 6.5 / 0.7 / 0 / Higher #: No policies requiring staff to check orders
8 / 660 / 115 tests / # requisitions with at least one error [a] /total requisitions received / 4.8 / 18 / 6 / 1 / Higher #Physicians allowed to order tests verbally
No policies requiring lab to confirm order accuracy
Order accuracy not monitored
Errors in test ordering: Anatomic Pathology
9 / 341 / 771 orders / # of requisitions with inadequate clinical data/total reacquisitions received / .73 [c] / Not Determined / Not determined
Errors in patient and specimen identification: Laboratory Medicine
10 / 712 / 2.46
Pts. Exams / # of patients with errors in wrist band identification [b]/total patients examined / 2.7 / 10.9 / Not determined / Higher #: Wristbands placed by nurses vs other health care workers.
Lower #: Policies requiring:
Written orders for removal of wristbands
Nursing personnel to be notified of patient ID
Incident reports documenting wristband misidentification
Continuous monitoring of wristband errors
Wristband id monitored upon pt. transfer to other locations
[d]
13 [e] / 660 / 16..5 trans-fusions / No. of patients adequately identified/total patients receiving blood / 62.3 25.4 / 10 0 / 69 10 / 92 73 / Higher #:Transport blood directly to pt. bedsides rather than through intermediary
locations
No more than 1 person handle blood en route;
Checking unit labels against orders
Pts. wear identification tags
Transfusionist reads id info aloud to assistant
No. pts. with vital signs adequately monitored /total patients receiving blood / 81.6 88.3 / 75 63.6 / 90.2 95 / 100 100 / Higher #: Using blood transfusion checklists
Instructing in transfusion practices
Routinely audit transfusions.
Errors in patient and specimen identification: Anatomic Pathology
16 / 417 / 1 M / # of requisition slips containing errors in patient and specimen identification/ total requisition slips received / 6 / Not determined / Higher #:policies
Allow requisition slips to be submitted unattached to specs.
Do not require specimen containers to be labeled with both pt. names and id #s.
Lower #:Written procedures for detecting errors in specimen accessioning and specimen identification
Errors in patient preparation and specimen acquisition:Laboratory Medicine
17 / 666 / 280
specs / # of digoxin doses given at incorrect times/total digoxin doses given / 22-31 / Not determined / Higher #:Absence of laboratory policies requiring times of the last dig. doses be written on requisition slips.
19 / 640 / 500 specs. / # of contaminated blood cultures/total number of cultures performed [f] / ND / 5.2-5.8 / 2.1-2.5 / 0.4-0.9 / Higher #: Lab (vs. non lab) workers collect specimens
Antisepsis of collection devices
Tincture of iodine used to cleans skin
20 / 906 / 200
specs / # of contaminated urine cultures / 18.1 / 36.8 / 10.1 / 5.6 / None Identified

NOTESFOR PRE ANALYTIC PHASE OF TESTING

[a] incorrect: transcription of requisitions into computer systems, recording of ordering MD, designation of test priorities and entry of test type.

[b] absent wristbands; incomplete, illegible, and erroneous information including identities belonged to other patients

[c] 6.1% of .73 required revising reports.

[d] The effects of policies allowing identification bands to be placed on locations other than on patients’ wrists (including hospital beds, walls and medical records) on the wristband error rates was inconsistent in these two studies. In the first study conducted in hospitals of all bed sizes, wristband error rates were lower in hospitals in which policies allowed this practice compared to hospitals in which policies did not allow this practice. In the second study conducted in small hospitals, precisely the opposite was true: in hospitals in which policies allowed placement of patient identification bands on sites other than patients, the error rates were higher

[e] also encompassed elements of post analytic phase

[e] Summary of two studies.

[f] calculated by laboratory assessment and clinical assessment on both inpatients and outpatients.

ANALYTIC PHASE OF TESTING

Reference / No. of institutions / Aggregate observations
(x 103) / Quality Indicator / Benchmark Data / Practice variables associated with benchmarks
Aggregate (%) / Institutional Percentiles(%)
10 / M / 90
Process errors: Anatomic Pathology
22 / 275 / 322
Specs. / # of slides containing extraneous tissue/# of slides examined [prospective(retrospective)] / .6
(2.9) / 1.8
(8.8) / 0.31
(1.0) / 0
(0) / None
# of blocks containing extraneous tissue/# of blocks examined [prospective(retrospective)] / .8
(3.7) / 2.22
(11.9) / 0.43
(1.1) / 0
(0)
# of specimens containing extraneous tissue/# of specimens examined [prospective(retrospective)] / 1.2
(5.4) / 3.36
(19.7) / 0.69
(1.9) / 0
(0)
# of cases containing extraneous tissue/# of cases examined [prospective(retrospective)] / 1.5
(6.2) / 4.28
(22.0) / 0.94
(2.5) / 0
(0)
23 / 359 / 1.670 Reports / # of amended reports issued/1000 surgical report / 1.9* / 1 / 5 / 21 / Higher: Case review after sign out
Lower: Case review before sign out
24 / 74 / 6.2 specs / # reports in which diagnostic interpretation differed upon post-sign out review by a 2nd pathologist/all cases reviewed by a 2nd pathologist / 6.7 / 5 / 1 / 0 / Lower: policies requiring original report to be deleted, replaced or designated as an amended report.
25 / 297 / 79.6 fsdx’s / No of discrepant frozen sections diagnoses/frozen section diagnoses (fsdx’s) made / 1.7 / Not determined / Not Determined
26 / 461 / 90.5 fsdx’s / 1.4
27 / 233 / 18.5 fsdx’s / 1.8
* included errors in final diagnoses 38.7%;change clinically significant information 26.5%),convert preliminary to final diagnoses (15.6%

POSTANALYTIC PHASE OF TESTING

Reference / No. of institutions / Aggregate observations
(x 103) / Quality Indicator / Benchmark Data / Practice variables associated with benchmarks
Aggregate (%) / Institutional Percentiles(%)
10 / M / 90
20 / 631 / 61.5 errors / # errors in laboratory report / Not determined / Not determined
18 / 623 / 13 telephone calls / # of critical value calls abandoned / all critical value calls made / 5 / Not determined / Not Determined

REFERENCES: (extracted from reference above. Only those papers cited in the table are given here).

7.Valenstein PN, Howanitz PJ. Ordering accuracy: a College of American Pathologists Q-Probes study of 577 institutions. Arch Pathol Lab Med 1995;119:117-122.

8.Valenstein PN, Meier F. Outpatient order accuracy: a College of American Pathologists Q-Probes study of requisition order entry accuracy in 660 institutions. Arch Pathol Lab Med 1999;123:1145-1150.

9.Nakhleh RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology. Arch Pathol Lab Med 1999 Jul;123:615-619.

10.Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals: a College of American Pathologists' QProbes study of quality issues in transfusion practice. Arch Pathol Lab Med 1993;117:573-577.

11.Howanitz PJ, Renner SW, Walsh MK. Continuous wristband monitoring over 2 Years decreases identification errors: a College of American Pathologists Q-Tracks study. Arch Pathol Lab Med 2002;126:809-815.

12.Dale JC, Renner SW. Wristband errors: data analysis and critique. 93-10. Small Hospital Q-PROBES. Northfield IL: College of American Pathologists; 1993.

13.Novis DA, Miller KA, Howanitz PJ, Renner SW, Walsh M. Audit of transfusion procedures in 660 hospitals: a College of American Pathologists Q-PROBES study of patient identification and vital sign monitoring frequencies in 16 494 transfusions. Arch Pathol Lab Med 2003:127:541548.:52-53.

16.Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: a College of American Pathologists Q-Probes study of 1,004,115 cases from 417 institutions. Arch Pathol Lab Med 1996;120:227-233.

17. Howanitz PJ, Steindel SJ. Digoxin therapeutic drug monitoring practices: a College of American Pathologists Q-Probes study of 666 institutions and 18 679 toxic levels. Arch Pathol Lab Med 1993;117:684-690.

19.Schifman RB, Strand CL, Meier FA, Howanitz PJ. Blood culture contamination: a College of American Pathologists Q-Probes study involving 640 institutions and 497,134 specimens from adult patients. Arch Pathol Lab Med 1998;122:216-221.

20.Valenstein P, Meier F. Urine culture contamination: a College of American Pathologists Q-Probes study of contaminated urine cultures in 906 institutions. Arch Pathol Lab Med 1998;122:123-129.

22.Gephardt GN, Zarbo RJ. Extraneous tissue in surgical pathology: a College of American Pathologists Q-Probes study of 275 laboratories. Arch Pathol Lab Med 1996;120:1009-1014.

23.Nakhleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: a College of American Pathologists Q-Probes study of 1,667,547 accessioned cases in 359 laboratories. Arch Pathol Lab Med 1998;122:303-309.

24.Raab S, Ruby S, Nakhleh R. Anatomic Pathology discrepancy rates and causes: data analysis and critique. QPO33. Q-PROBES. Northfield IL: College of American Pathologists; 2003.

25.Zarbo RJ, Hoffman GG, Howanitz PJ. Interinstitutional comparison of frozen-section consultation: a College of American Pathologists QProbe study of 79 647 consultations in 297 North American institutions. Arch Pathol Lab Med 1991;115:11871194.

26.Gephardt GN, Zarbo RJ. Interinstitutional comparison of frozen section consultations: a College of American Pathologists Q-Probes study of 90 538 cases in 461 institutions. Arch Pathol Lab Med 1996;120:804- 809.

27.Novis DA, Gephardt GN, Zarbo RJ. Interinstitutional comparison of frozen section consultation in small hospitals: a College of American Pathologists Q-Probes study of 18 532 frozen section consultation diagnoses in 233 small hospitals. Arch Pathol Lab Med 1996;120:1087-1093.

18.Howanitz PJ, Steindel SJ, Heard NV. Laboratory critical values policies and procedures: a College of American Pathologists Q-Probes study in 623 institutions. Arch Pathol Lab Med 2002;126:663-669.

29.Howanitz PJ, Walker K, Bachner P. Quantification of errors in laboratory reports: a quality improvement study of the College of American Pathologists’ QProbes program. Arch Pathol Lab Med 1992;116:694-700.