I have been looking at 'Pathology Clinical Incidents' recently, and was
surprised to find how many of these concerned the pre-analytical phase -
for example, here in August there were two identified cases of a sample
taken from the wrong patient, and one where an incorrect preservative (not
identified on the sample tube) was used for the sample. However, I have
only just realized that potentially I am sitting on a very large number of
potentially serious incidents arising at or before the book-in stage of the
Pathology process. There is also a very grey area of 'where does the
responsibility lie?'
For example, take a 16-week pregnant patient who should have a serum sample
taken for AFP in a screening programme for neural tube defects.
If a sample is never taken, I do not think this is a Pathology clinical
incident.
The grey areas are:
AFP is requested but in the wrong area of the request card, for example the
area for 'Clinical information';
AFP is requested, but the hand-writing is so indecipherable it is
interpreted as a request for another test.
The non-grey area is if AFP is requested, but an error occurs at data
input, so that it is either missed or coded as another test; and this is
not detected by the Duty Biochemist.
If the missing test is not noticed for a couple of months if at all, and
the woman eventually produces a NTD baby, this is clearly a major pathology
clinical incident.
I am now trying to quantify how often such errors occur. Has anyone else
looked at this area? Do any quality standards exist?
Gordon Challand
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