A benchmark audit of the types and frequency of pathology errors recorded in central specimen reception

Introduction
Errors in laboratory medicine can occur at any stage of the pathology request-test-report cycle. Many pathology services maintain an error log in order to monitor errors associated with laboratory test requests. This study undertook an audit of a Central Specimen Reception (CSR) error log to identify the types of errors and their causes and provide a benchmark for future studies and quality improvement exercises.

Methods
Data from the paper-based CSR error log of a pathology service supporting three Sydney hospitals were collected for a six-month period (January to June 2009). A researcher with laboratory experience, in consultation with CSR staff, audited the error log. Process maps of workflow were generated to identify the impact of errors. Regular iterative feedback sessions were held with senior staff to confirm the validity of the findings.

Results
Errors were divided into two broad classes. 1) Incident Information Management System (IIMS) errors which pose a risk to patient safety; these occurred at a rate of 2.43 per 1000 test order episodes. 2) Efficiency and effectiveness errors which may delay or hamper the availability of a validated laboratory result; these occurred at a rate of 2.80 per 1000 test order episodes.

Conclusion
The classification of errors into a patient safety and laboratory performance nomenclature facilitated the generation of benchmark rates for different categories of errors. These base-rates are valuable in quality monitoring and for the evaluation of changes within the pathology service e.g. the implementation of an electronic medical record.