Posted by Sten Westgard, MS

It's almost mandatory that any presentation or report discussing patient safety references the landmark IOM report of 2000: To Err is Human - Building a Safer Health System. The takeaway quote from this report is that US hospitals were causing 44,000 to 98,000 deaths that were otherwise preventable. That is, hospitals were causing tens of thousands of avoidable deaths.

A recent paper has attempted to revise that estimate, focusing on Preventable Adverse Events (PAEs) that contributed to the death of patients. Can you guess how lethal US hospitals are now?

1. 4,000 to 10,000 PAEs per year
2. 44,000 to 98,0000 PAEs per year
3. 100,000 to 200,000 PAEs per year
4. 210,000 to 440,000 PAEs per year

The answer, after the jump...

Posted by Sten Westgard, MS

Recently, the Journal of Veterinary Diagnostic Investigation had an interesting paper on error rates:

An error management system in a veterinary clinical laboratory, Emma Hooijberg, Ernst Leidinger, Kathleen P Freeman, J Vet Diag Invest 2012 24(3): 458-468.

If we look at error rates in a vet lab, do you think they're better or worse than the "normal" clinical laboratory? The results may surprise you...

Posted by Sten Westgard, MS

A lot of interesting studies coming out this month, unfortunately none of them with encouraging news about the US healthcare system.

The latest, from Sunil Eappen, MD, Atul Gawande, MD et al, Relationship Between Occurence of Surgical Complications and Hospital Finances, JAMA, April 17, 2013, Vol. 309, No. 15 1599-1606

Take a guess: do US hospitals make more money when things go wrong, or less?

Posted by Sten Westgard, MS

Can you guess which of these categories is the leading source of successful malpractice claims?

• Surgical mishaps
• Obstetrical problems
• Medication errors
• Anesthesia disasters
• Diagnostic errors
• Treatment errors
• Something else entirely?

The answer, after the jump...

Posted by Sten Westgard, MS

More evidence of pre-analytical error rates, this time for the Journal of Clinical Pathology. This is from a study back in 2010, my apologies for only finding it this year:

A Six Sigma approach to the rate and clinical effect of registration error in a laboratory, Naadira Vanker, Johan van Wyk, Annalise E. Zemlin, Rajiv T Erasmus, J Clin Pathol 2010:63:434-437.

In this study, they reviewed 47,543 test request forms from a 3 month period of November 2008 to February 2009. The study was conducted at the "chemical pathology laboratory at Tygerberg Hospital - an academic tertiary hospital in the Western Cape Province of South Africa. The laboratory is a division of the National Health Laboratory Services, which is a network of 265 pathology laboratories in South Africa."

Can you guess how many errors they found? And what was the impact of those errors?

Posted by Sten Westgard, MS

In the December 2011 issue of Point of Care journal, an interesting study was published:

Preanalytical Errors in Point-of-Care Testing: Auditing Error of Patient Identification in the Use of Blood Gas Analyzers, Natalie A Smith, David G Housley, Danielle B. Freedman, Point of Care, Volume 10: Number 4, December 2011.

The study looked at patient identification errors on a blood gas analyzer in various departments in a hospital. Bearing in mind that this is just one type of pre-analytical error, what do you think the rate was? Given around 100,000 tests, what would you guess as the number of defects?

Posted by Sten Westgard, MS

[Hat-tip to the AACC Point-of-Care listserve, which first posted a notice about this article]

The Pennsylvania Patient Safety Advisory has a regular electronic newsletter highlighting new science and studies about healthcare safety. Their December 2011 issue has a particularly interesting article for laboratory testing:

Point-of-Care Technology: Glucose Meter's Role in Patient Care, Lea Anne Gardner, PhD, RN, Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority.

This review examined more than 1,300 reports of glucose-meter problems from the Pennsyvlania reporting system database from 2004 to 2011. Of those reports, 71 near-miss or adverse event reports occurred. Most intriguing are the report excerpts directly quoted in the study. Of those reports, 72% of the near-miss or adverse events occurred with high-blood glucose results. That is, where the glucose meter had a sudden high value that may or may not have been reflective of the actual patient's clinical state. For example:

"A patient's blood sugar was checked using a [glucose meter]. The lunchtime result was 517. A [blood glucose test] was [immediately] retaken to check for accuracy, and the result was greater than 600. A blood [laboratory] test was conducted per protocol, and the [lab] glucose [result] was 136..."

What do you think happened next?

Posted by Sten Westgard, MS

Here's an eye-opening report from the Office of Inspector General from the Department of Health and Human Services: Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries

So what's your best guess on the frequency of adverse events?

Posted by Sten Westgard, MS

Why do some numbers and statistics in the laboratory attract more attention than others?

While we consider ourselves scientists who make decisions based on rational cost-benefit analyses, an objective look at some of our priorities often reveals the opposite. Labs often make decisions and set priorities based on the emotions of the moment, rather than a cold analysis of the data.

Let's put it another way. There is an infamous quotation attributed to Stalin: "When one man dies it is a tragedy, when thousands die it's statistics."

Do labs respond more to individual tragedies or their own statistics?

Posted by Sten Westgard, MS

 One more shot at error rates! At the IFCC Berlin conference, there was an intriguing abstract about the use of Quality Design/Planning tools in the laboratory:

Abstract #1062: Efficiency of Analytical Qualit yControl with Various Quality Planning Tools in Thai Clinical Laboratory. K. Sirisali, S. Manochiopinj, S. Sirisali.

How high do you think out-of-control rates can go?

Posted by Sten Westgard, MS

Earlier we discussed error rate issues at the Point-of-Care. But we didn't want to leave the "regular" laboratory out of the fun, so here's a study of error rates that came out in 2010:

Evaluation of errors in a clinical laboratory: a one-year experience, Goswami B, Singh B, Chawla R, Mallika V, CCLM 2010;48(1):63-66.

A new study in Clinical Chemistry investigated the errors rates for Point-of-Care (POC) devices:

Quality Error Rates in Point-of-Care Testing, O'Kane MJ, McManus P, McGowan N, Lynch PL, Clin Chem 2011 Sep;57(9):1267-1.

Can you guess what the error rates were?

Posted by Sten Westgard, MS

A recent news investigation produced a litany of laboratory errors. Can you guess which of these lab errors actually happened?

• a blood screening test fails to identify a critical blood disorder in a pregnant woman. Her child dies 3 weeks after being born
• an HIV test falsely identifies a husband as HIV positive. The couple separates, the wife unwilling to trust the husband anymore.
• a paternity test sample gets switched: a father is falsely told that his daughter is not his biological child. The family splits up. Nearly 4 years later, the laboratory contacts him and tells him he was the father. The father-daughter bond remains broken.

The answer, after the jump.

Posted by Sten Westgard, MS

A recent article about the experience of QMS tracking in a clinical laboratory in Nigeria raised some interesting questions about sources of errors in "developing world" laboratories.

Where would you expect a Nigerian Human Virology laboratory (HVL) to experience the most problems?

• pre-analytical processes
• analytical processes
• post-analytical processes

The answer, after the jump...

Posted by Sten Westgard, MS

I came across a very valuable paper in Clinica Chimica Acta on the stability of hematology controls for MCV. (Some of you are already guessing what this is going to be about...)

If you take a hematology control, how many SDs should you expect to see it shift at week 5 of use versus the first week of use? In other words, what is the SDI you should expect?

• 1 SDI
• 2 SDI
• 3 SDI
• 4 SDI
• 5 SDI
• higher than 5 SDI

The answer, after the jump...

Posted by Sten Westgard, MS

According to a recent CAP Q-Probe, approximately how many glucose tests are being bracketed by QC events?

Is it

• 5,000 tests between QC runs
• 500 tests between QC runs
• 50 tests between QC runs
• 5 tests between QC runs

The answer, after the jump

Posted by Sten Westgard, MS

Diagnostic errors are one of the "new" hot topics in the healthcare field. A new study from British Medical Journal of Quality and Safety has a chilling estimate of just how common diagnostic errors are occurring in outpatient settings.

So what's your guess? How often in the US are diagnostic errors being made in outpatient settings?

• about 1 in 5 visits
• about 1 in 10 visits
• about 1 in 20 visits
• about 1 in 50 visits
• about 1 in 100 visits

The study's conclusion, after the jump...

Posted by Sten Westgard, MS

Earlier this month (July) I came across a series of revealing posts on a listserv about the quality of  glucose meters. For me, it raised the question, just what defect rate is acceptable at the point of care?

• 0.00034%
• 1%
• 5%
• 10%
• 40%
• 75%
• 100%

What level of defect rate do you believe is being seen at the point of care? the answer (after the jump) might astonish you...

Posted by Sten Westgard, MS

While we recently got a study that estimated the (frightenly high) number of Adverse Events caused by US hospitals, it looks like other countries are not content to let us stand alone. Now Sweden is doing us one better. Guess what the Adverse Event rate is in one hospital in Sweden?

• 28.2%
• 20.5%
• 6.3%
• 3.32%

 Which number would you choose?

Posted by Sten Westgard, MS