Ann Clin Biochem OnlineFirst, published on September 9, 2016 as doi:10.

1177/0004563216669384

DOI: 10.1177/0004563216669384

Pre-Analytical Errors in Medical Laboratories: A review of

the available methodologies of data collection and analysis

Journal: Annals of Clinical Biochemistry

Manuscript ID ACB-16-165.R2

Manuscript Type: Review Article

Date Submitted by the Author: 03-Aug-2016

Complete List of Authors: West, Jamie; Peterborough and Stamford Hospitals NHS Foundation Trust,
Department of Clinical Biochemistry and Immunology; ACB Special Interest
group for the preanalytical phase
Atherton, Jennifer; Liverpool Clinical Laboratories, Blood Sciences; ACB
Special Interest group for the preanalytical phase
Costelloe, Sean; Plymouth Hospitals NHS Trust, Derriford Combined
Laboratory; ACB Special Interest group for the preanalytical phase
Pourmahram, Ghazaleh; BD Diagnostics, Preanalytical Systems; ACB
Special Interest group for the preanalytical phase
Stretton, Adam; BD Diagnostics, Preanalytical Systems; ACB Special
Interest group for the preanalytical phase
Cornes, Michael; New Cross Hospital, Clinical Chemistry; ACB Special
Interest group for the preanalytical phase

Keywords: Quality assurance & control < Laboratory methods

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2
3 Pre-Analytical Errors in Medical Laboratories: A review of the available methodologies of data
4 collection and analysis
5
6
7 Authors
8
9 Jamie West1, Jennifer Atherton2, Seán J. Costelloe3, Ghazaleh Pourmahram4, Adam Stretton4 ,
10
Michael Cornes5
11
12
1
13 Department of Clinical Biochemistry and Immunology, Peterborough City Hospital, United Kingdom
14 2
Liverpool Clinical Laboratories, Blood Sciences Department, Aintree University Hospital, Liverpool,
15 3
Derriford Combined Laboratory, Plymouth Hospitals NHS Trust, Plymouth, Devon, United Kingdom
16 4
17 Becton Dickinson Diagnostics, Preanalytical Systems (PAS), The Danby Building, Edmund Halley
18 Road, Oxford Science Park, Oxford, OX4 4DQ.
5
19 Clinical Chemistry Department, New Cross Hospital, Wolverhampton, United Kingdom
20 This paper was written by the Association for Clinical Biochemistry and Laboratory Medicine [ACB]
21 Special Interest Group for the pre-analytical phase
22
23
24 Running Title: Standardization of Preanalytical Phase KPI collection
25
26 Keywords: Pre-analytical errors, quality indicators, laboratory errors, patient safety
27
28
29 Correspondence to:
30 Dr Michael Cornes
31 Department of Clinical Chemistry,
32 New Cross Hospital,
33
34 Wolverhampton, WV10 0QP,
35 UK.
36 Tel: 01902 307999 ext 3644
37 Fax: 01902 695618
38
39 E-Mail: michael.cornes@nhs.net
40
41 DECLARATIONS
42 Competing interests: None
43
44
Funding: None
45 Ethical approval: Not required.
46 Guarantor: MC
47 Contributorship: All conceived and discussed study. JW wrote the first draft. All edited manuscript
48
Acknowledgements: none
49
50 Abstract Word count: 226
51 Main text word count: 3097
52
53
Keywords
54
55
56 Pre-analytical errors, quality indicators, laboratory errors, patient safety
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3 Abstract
4
5
Pre-analytical errors (PAEs) have previously been shown to contribute a significant proportion of
6
7 errors in laboratory processes, and contribute to a number of patient safety risks. Accreditation
8 against ISO 15189:2012 requires that laboratory Quality Management Systems consider the impact
9 of pre-analytical processes in areas such as the identification and control of non-conformances,
10
continual improvement, internal audit and quality indicators (QIs). Previous studies have shown that
11
12 there is a wide variation in the definition, repertoire and collection methods for pre-analytical QIs.
13 The International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient
14 Safety (IFCC-WG-LEPS) has defined a number of QIs for the pre—analytical stage, and the adoption
15
of harmonised definitions will support inter-laboratory comparisons and continual improvement.
16
17 There are a variety of data collection methods, including audit, manual recording processes, incident
18 reporting mechanisms and laboratory information systems. Quality management processes such as
19 benchmarking, statistical process control, Pareto analysis and Failure Mode and Effect Analysis
20 (FMEA) can be used to review data, and should be incorporated into clinical governance
21
22 mechanisms.
23 In this paper The Association for Clinical Biochemistry and Laboratory Medicine Pre-Analytical
24 Specialist Interest Group (ACB-SIG-PA) review the various data collection methods available. Our
25 recommendation is the use of the laboratory information management systems (LIMS) as a
26
27 recording mechanism for pre-analytical errors as this provides the easiest and most standardised
28 mechanism of data capture.
29
30 Introduction
31
32
33 Pre-analytical errors (PAEs) are errors which occur prior to the analytical stage in the total testing
34 process (TTP), and can occur both before and after receipt of specimens in the laboratory. They have
35 previously been shown to contribute a significant proportion of errors in laboratory processes (up to
36
37 68.2%).1,2,3 PAEs contribute to a number of patient safety risks including inappropriate or incorrect
38 therapeutic interventions, unnecessary follow-up investigations and diagnostic delays, each of which
39 impact on the clinical and economical effectiveness of Pathology services.4,5,6
40
41
42
Requirements for accreditation against ISO 15189:2012 (Medical laboratories — Requirements for
43 quality and competence) dictate that laboratories should consider pre-analytical processes in a
44 number of areas of the quality management system, including the identification and control of non-
45 conformances, continual improvement, internal audit and quality indicators (QIs)7. It states that ‘the
46
laboratory shall establish quality indicators to monitor and evaluate performance throughout critical
47
48 aspects of pre-examination, examination and post-examination processes’. In the UK, a recent
49 report into the quality assurance frameworks and governance systems highlighted variations in the
50 processes for error reporting, advising that high levels of error reporting with low overall error rates
51
is a good indicator of a quality service .8
52
53
54 In a previous study by the Association for Clinical Biochemistry and Laboratory Medicine Pre-
55 Analytical Specialist Interest Group (ACB-SIG-PA), we have shown that there is a wide variation in the
56
definition, repertoire and collection methods for pre-analytical QIs.9 Here we aim to review potential
57
58 methodologies for the monitoring of PAEs, including recording of errors, data collation and review,
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3 follow-up data outputs and integration into a clinical governance framework. It is hoped that
4 consideration of data collection methods will help to standardise data, allow development of key
5
performance indicators (KPIs) and support peer review and continual improvement.
6
7
8 Types of pre-analytical errors
9
10
A key source of variation identified in the Pathology Quality Assurance Review8 was the definition of
11
12 errors. Standardisation in this area underpins effective reporting of errors, enabling comparisons
13 between peers and identification of areas for improvements in the total testing process (TTP). These
14 QIs then provide a harmonised platform for targeted continuous improvement and a means of
15
measuring said improvements.10 The International Federation of Clinical Chemistry Working Group
16
17 on Laboratory Errors and Patient Safety (IFCC-WG-LEPS) has worked to improve awareness in the
18 field of laboratory errors and patient safety, developed pilot studies to monitor error rates and
19 implemented projects to reduce errors. One element of the project has been to develop QIs to
20 support the monitoring of critical steps in the Pathology process. Table 1 details a selection of
21
22 harmonised QIs for the pre-analytical stage suggested by the working group to be mandatory to a
23 laboratory’s quality monitoring processes.11
24
25 These suggestions outline a number of common areas of the pre-analytical laboratory processes
26
27 where errors can occur, but are not an exhaustive list. Laboratories should consider the risks
28 associated with each step in the TTP for the services they offer, and look to ensure that processes
29 are in place to identify process failures and monitor their rates of incidence. This project has also
30 triggered the development of other country specific pre- and post-analytical external quality
31
32 assurance (EQA) schemes which will further drive the need to standardise collection methods.12
33 Further consideration of harmonised definitions of QIs may be required moving forward. For
34 example, the IFCC-WG-LEPS defines the presence of haemolysis in Clinical Chemistry samples as a
35 free haemoglobin concentration of >0.5g/L, while a variety of laboratory tests are affected by
36
37 haemolysis at lower and higher concentrations of free haemoglobin, and practice regarding the
38 handling of haemolysed specimens may vary between laboratories. Requirements for the labelling of
39 samples will also vary between laboratories, with transfusion laboratories an example where minor
40 errors will result in rejection, and where the IFCC-WG-LEPS definition of an inadequately labelled
41
42
sample as one which has ‘less than 2 identifiers’ may not be suitable. As laboratories looked to
43 define and standardise their own definitions of laboratory errors, it is hoped that peer comparison
44 schemes will support harmonised approaches to detecting and reporting laboratory errors.
45
46
Recording of errors
47
48
49 In order for laboratories to monitor the error rates for their services, a robust continuous
50 mechanism of error collection must be established. When considering the systems used for
51
highlighting quality failures, it is important to ensure that the processes are easy to use and
52
53 understood by staff in the laboratory tasked with recording errors. Standardisation of processes is
54 important to ensure the accuracy of the recording mechanisms and enable effective staff training. To
55 this end all error collection procedures must be contained in a standardised operating procedure
56
which states not just how to collect data but also collection frequency and what to do when error
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3 frequencies are outside pre-defined action limits. Below we detail a number of options for
4 mechanisms to monitor error rates:
5
6
7 Audit
8
9 Laboratory quality audit is an essential element of a laboratory’s quality management system, and
10
should include scheduled audits of process effectiveness. ISO 15189: 2012 states that this should
11
12 incorporate audits of pre-analytical areas to collect information on the relative rates of errors.
13 Examples of such audits might be: an audit of request forms to identify the percentage which do not
14 have complete information regarding the requester; an audit of specimens to identify the
15
percentage which do not have complete (or accurate) patient information; an audit of ‘booking-in’
16
17 processes to identify the percentage of booking in errors.
18 While audit forms a crucial part of the laboratory’s quality processes, the use of audit itself as a tool
19 for data collection is limited as it is retrospective. Therefore, audit does not provide a real time
20 assessment of rates of error incidence, but a survey of error rates at a particular point in time.
21
22 Further, audit does not immediately alert users to the quality issues with their requests. Finally,
23 audits must be extensive in order to accurately reflect the true error rate of the laboratory, and as
24 such are labour intensive to perform.
25
26 Manual recording processes
27
28 Systems of recording errors manually by means of ‘Quality Query Reports’ (QQRs) have been
29
described previously.13 QQRs involve the use of report forms made available at workstations to
30
31 records errors. The process is, again, labour intensive compared to automated systems of error
32 identification in terms of both error recording and especially in reviewing data, and as such risks
33 lower levels of compliance and under-reporting of errors. Variable frequencies in recorded errors
34
which may be reflective of variations in compliance the recording process have been anecdotally
35
36 observed and would be expected due to human factors. Such systems also have the disadvantage
37 that they do not alert the user to quality failures.
38
39 Incident reporting
40
41 Incident reporting, often using risk management software such as Datix (Datix Limited, London, UK),
42 should be part of any healthcare provider’s clinical governance processes. Medical laboratories
43
should have processes of reporting errors using these systems. These systems have the advantage of
44
45 being subject to host organisation governance processes. However, given the in-depth nature of
46 reporting required, such systems are not suited to recording large numbers of lower risk errors.
47
48 Use of laboratory information management systems
49
50 Laboratory information management systems (LIMS), primarily used to record receipt of specimens
51 and report results, have the potential to be used to record quality errors, report them to users, act
52
53 as repositories of error data, and also gather data on error rates. Sub-clause 5.8.2 of the ISO 15189:
54 2012 Standard concerns report attributes, and states that the report should contain ‘comments on
55 sample quality that might compromise examination results’ and ‘comments regarding sample
56 suitability with respect to acceptance/rejection criteria’.7 Many errors will still require manual
57
58 identification but the use of the LIMS systems to record quality failures has the advantage that
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3 simple and standardised processes can be developed which makes error logging part of the normal
4 sample receipt process and improves compliance. In the automated laboratory some errors have the
5
potential to be both identified and entered into the LIMS automatically e.g. delayed transit,
6
7 underfilled tubes, wrong specimen type etc. LIMS use is both prospective (as opposed to
8 retrospective methods described above) in alerting users to quality failures and retrospective when
9 regular data extractions are performed for trend analysis. Setting up such processes is often labour
10
intensive, however once in place, there is minimal staff time associated with collecting and
11
12 extracting the data.
13
14 Suggestions for recording errors via LIMS systems include:
15
16 • Use of ‘Report Comment’ fields to record quality failures and highlight them in the report.
17
For such systems, a balance between the standardisation of error codes (which improves
18
19 information gathering and review) and the flexibility to record errors of a variety of sources
20 is required.
21 • Use of a test field in the LIMS system which can be used to record a number of laboratory
22
errors that can then be reported to the user (i.e. book in a test that indicates an error and
23
24 result this test with a coded comment to indicate the type of error).
25 • Use of coded comments in place of results for samples that cannot be analysed, e.g. HAEM
26 for samples that cannot be analysed due to haemolysis
27
28 • Key word searches for comments in reports, e.g. ‘haemolysis’
29
30 The configuration of the recording system will depend on the configuration of the LIMS system (and
31 potentially other associated operating systems and middleware), and will have to be adapted to
32 allow the recording of a variety of types of error. Laboratories should consider the merits of their
33 LIMS systems when designing systems of recording errors. An ideal process will allow errors to be
34
35 easily recorded in the laboratory, clearly reported to users and support the export and review of
36 data for continuous improvement.
37
38 Data review
39
40 The advantage of using LIMS based systems for the recording of errors is that it is possible to access
41 real-time and/or retrospective data for review in a simple and effective way. Data export processes
42
such as FTP (File Transfer Protocol) or database enquiries enable data to be reviewed quickly and
43
44 easily. Data should be reviewed and published to laboratory users periodically. Trends and patterns
45 should be investigated in conjunction with the department involved. Data to review include:
46
47 • Types of errors – error types (for example as described in Table 1) can be reviewed for
48 trends and changes
49
50 • Requesting locations – this can be important in identifying areas with high error rates for a
51 particular indicator, such as specimen collection, transport or haemolysis, which may be a
52 systematic issue relating to a particular service user. In such cases, training in specimen
53 collection and/or improvements in logistics can have a beneficial impact on reducing error
54
55 rates and therefore reducing repeat venepunctures and costs. Reporting to groups of clinical
56 teams (for example laboratory service commissioning groups or hospital clinical teams) may
57 also be useful for establishing governance processes using laboratory data
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3 • Requesting clinicians – error rates relating to requesting (for example appropriateness of a
4 request or completion of a request form)
5
6 • Errors by laboratory department – this could indicate an issue with intra lab sample
7 processing
8
9 There are a number of quality management tools which can be utilised in the investigation of
10 laboratory quality errors, including:
11
12 • Benchmarking – error rates are compared against locally or nationally derived benchmarks
13
or against other laboratories
14
15 • Statistical process control – in the same way that the laboratory reviews quality control data
16 for outliers, error rates can be compared against a target mean and standard deviations to
17 identify statistically significant changes
18
• Failure mode and effect analysis (FMEA) – FMEA requires a knowledge of the steps involved
19
20 in the testing process, target areas of high risk and looks at methods of adapting processes
21 to reduce failures14
22 • Pareto analysis – Pareto diagrams organise elements in order of frequency of occurrence,
23
enabling the laboratory to target areas of high risk. Errors can be grouped as described
24
25 above, for example, by error type or location
26
27 Laboratory errors and Clinical Governance
28
29 Once data are established for measuring rates of pre-analytical laboratory errors, it is important to
30 incorporate the information into the department’s quality management system and clinical
31 governance processes.
32
33
Key performance indicators
34
35
Key performance indicators (KPIs) are measurands used by organisations to monitor and assess their
36
37 effectiveness. In clinical laboratory services a number of indicators have been suggested,15,11 many of
38 which relate to issues regarding pre-analytical errors. In the UK a recent Pathology Quality Assurance
39 Review8 describes the use of Pathology quality assurance dashboards (PQAD) to ensure Pathology
40
providers comply with service specifications, and suggests that the dashboards should be developed
41
42 with commissioners of Pathology services. There have been previous attempts to develop
43 performance measures for Pathology services16 and a UK national project is underway to develop a
44 dashboard. PQADs can serve the dual purpose of allowing a laboratory to monitor key areas of its
45 service (which includes elements from the pre-analytical phase) and also provide data to users on
46
47 the effectiveness of its service.
48
49 Risk management
50
51 Clause 4.14.6 of the ISO 15189: 2012 standard7 relates to risk management, and is a core area of the
52 standard. It advises that the laboratory should ‘evaluate the impact of work processes and potential
53 failures on examination results as they affect patient safety, and shall modify processes to reduce or
54
eliminate the identified risks and document the decisions and actions taken’. Pre-analytical steps in
55
56 examination processes, including those that occur before the sample is received in the laboratory,
57 are a key source of error in the TTP and risk management processes should incorporate such errors.
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3 The ISO Technical Specification 22367: 2008 ‘Medical Laboratories – reduction of error through risk
4 management and continual improvement’17 advises that laboratories should have processes for:
5
6 • Identifying high-risk processes where the potential error could lead to a safety risk for
7
8
patients
9 • Identifying actual incidents associated with deviations from standard procedures
10 • Estimating and evaluating the associated risks to patient safety
11
• Controlling these risks
12
13 • Monitoring the effectiveness of the control undertaken
14
15 ISO/TS 22367:2008 also recommends assigning actual (A) and potential (P) scores to the risks
16 associated with processes, based on the potential impact of the errors on patient safety.
17 Laboratories that frequently monitor rates of laboratory errors in the pre-analytical phase, and use
18
the information to facilitate preventative action to improve processes, are in a good position to
19
20 monitor the impact of such errors on the results they report and assess the impact on patient safety.
21
22 Interventions
23
24 Efforts to decrease rates of pre-analytical errors have been documented previously but can be
25 difficult. For example, Kemp et al18 used posters and screen savers to improve user awareness of
26 testing protocols but showed no statistically significant change in the frequency of errors. Salinas et
27
28 al, however combined improvement actions (such as educational programs for nurses, technological
29 interventions to automate manual steps in phlebotomy procedure and communication between the
30 laboratory and peripheral community centres) with monitoring via a balanced scorecard to show an
31 improvement in pre-analytical error rates over a 10-year period.19
32
33 If it is assumed that laboratory testing protocols across different clinical areas have a consistent rate
34
35 of occurrence within a defined variation, an alternative approach is to target interventions to areas
36 which have higher error rates, for example higher rates of sample haemolysis or labelling errors.
37 Here FMEA with interventions such as training or process changes may be more effective. For
38 example, some of the key causes of sample haemolysis relate to the blood collection step, and
39
40 overly vigorous collection.20 If areas are identified where haemolysis rates are higher than expected
41 training and communication can be targeted to reduce this risk.
42
43 When targeting interventions to reduce error rates it is important to approach issues in a ‘system’
44 based manner, as opposed to taking an ‘individual’ approach.21 This approach emphasises looking at
45 the processes that a laboratory puts in place, in this case pre-analytical processes such as sample
46
47 collection and transport, to identify opportunities for improvement.
48
49 Conclusions
50
51 Pre-analytical errors continue to represent the largest source of errors in the TTP. Harmonised QIs
52 for pre-analytical errors have been suggested,11 which allow consistent and efficient reporting via the
53 laboratory’s quality monitoring processes. Although it is a challenge to ensure compliance in
54
recording such errors, the use of the LIMS and/or middleware allows consistent recording of errors,
55
56 alongside manual reporting by laboratory staff, and the end users.
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3 Once data have been effectively gathered by the laboratory, risk analysis using FMEA, and reporting
4 of data using PQADs allows judgement about the severity and incidence of pre-analytical errors.
5
Interventions can then be planned and prioritised, according to the data reported. Previous studies9
6
7 have shown variation in data collection processes, which will limit the effectiveness of peer
8 comparisons and as such inhibit opportunities for continual improvement. The process of data
9 collection must therefore be standardised to allow comparisons to benchmarked data which will
10
drive improvement in this area. Laboratories should carefully consider their processes to monitor
11
12 pre-analytical errors to ensure that the processes for obtaining data are effective and areas of risk
13 are monitored to enable quality improvement in the TTP.
14
15 In conclusion, the ACB-PA-WG recommends the use of the LIMS as a recording mechanism as in the
16 long term this provides the easiest and most standardised mechanism of data capture. The ACB-SIG-
17
PA also recommends that the ability to provide such data should be a criterion when tendering for
18
19 new LIMS systems in order to transfer the responsibility for developing mechanisms to the experts
20 and produce standardised data. Other mechanisms are retrospective and have been shown to under
21 report errors. Data from KPIs should be available to users and compared to benchmarked data or
22
against peers.
23
24
References
25
26
27
1. Plebani, M., Carraro, P. Mistakes in a stat laboratory: type and frequency Clin Chem, 1997,
28 43:8 1348-1351
29 2. Plebani, M Errors in clinical laboratories or errors in laboratory medicine Clin Chem Lab Med
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3. Kalra J. Medical errors: impact on clinical laboratories and other critical areas. Clin Biochem
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33 2004; 37: 1052–1062.
34 4. Cadamuro, J., Wiedermann, H., Mrazek, C., Felder, CK., Oberkofler, H., Fielder, GM.,
35 Haschker-Becher, E. The economic burden of hemolysis Clin Chem Lab Med 2015; 53(11),
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285-8
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38 5. Green, SF., The cost of poor blood specimen quality and errors in pre-analytical processes Clin
39 Biochem 2013; 46, 1175-1179
40 6. Jacobs P, Costello S, Beckles M. Cost of haemolysis. Ann Clin Biochem. 2012;49(Pt 4):412
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7. ISO 15189:2012, Medical laboratories -- Requirements for quality and competence
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43 8. Pathology Quality Assurance Review, Dr Ian Barnes, Jan 2014.
44 9. Cornes MP, Atherton J, Pourmahram G, Borthwick H, Kyle B, West J, Costelloe S Monitoring
45 and reporting of preanalytical errors in laboratory medicine: the UK situation Ann Clin
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Biochem 2016; 53(2) 279-284
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48 10. Plebani, M. Quality Indicators to Detect Pre-Analytical Errors in Laboratory Testing Clin
49 Biochem Rev 2012, 33, 85-88
50 11. Plebani M., Sciacovelli L., Aita A., Chiozza ML. Harmonisation of pre-analytical quality errors
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Biochemica Medica 2014; 24(1): 105-13
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53 12. Cornes MP, Church S, van Dongen-Lases E, Grankvist K, Guimarares JT, Ibarz M, Kovalevskaya
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55 Federation of Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical
56 Phase in standardization and harmonization of the preanalytical phase in Europe Ann Clin
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3 13. O’Kane, MJ, Lynch, PLM, McGowan, N The development of a system for the reporting,
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7 14. Agarwal, R. Measurement of Errors in Clinical Laboratories Ind J Clin Biochem 2013; 28(3)
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9 15. Barth, JH Clinical quality indicators in laboratory medicine Ann Clin Biochem 2012; 49: 9-15
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16. Royal College of Pathologists Key Performance Indicators – Proposals for Implementation
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12 (available from https://www.rcpath.org/resource-library-homepage/clinical-
13 effectiveness/key-performance-indicators-kpi.html)
14 17. ISO/TS 22367: 2008, Medical laboratories -- Reduction of error through risk management
15
and continual improvement
16
17 18. Kemp, GM, Bird CE, Barth JH Short-term interventions on wards fail to reduce preanalytical
18 errors: results of two prospective controlled trials Ann Clin Biochem 2012; 49 166-169
19 19. Salinas M., Lopez-Garrigos M., Flores E., Santo-Quiles A., Gutierrez M., Lugo J., Lillo R., Lieva-
20 Salinas, C. Ten years of pre-analytical monitoring and control: Synthetic Balance Score Card
21
22 Indicator Biochemic Medica 2015; 25(1): 49-56
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24 Clinical Challenge? Clin Chem. 2000 Feb;46(2):306-7.
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4 Table 1 – Mandatory Quality Indictors of the Pre-Analytical Phase as suggested by IFCC-WG-LEPS
5
6
7 Step in process Associated quality indicators
8 Patient Identification • Number of requests with errors concerning patient identification
9 (%)
10 • Number of requests with errors concerning patient identification
11 detected before the release of results (%)
12 • Number of requests with errors concerning patient identification
13
detected after the release of results (%)
14
Data entry of the • Number of requests with errors concerning test input (%)
15
16 request • Number of requests with errors concerning test input (missing,
17 %)
18 • Number of requests with errors concerning test input (added, %)
19 • Number of requests with errors concerning test input
20 (misinterpreted, %)
21 Sample identification • Number of inadequately labelled patient samples (%)
22
Sample collection • Number of samples collected with inappropriate sample tube
23
24
type (%)
25 • Number of samples collected in inappropriate container (%)
26 • Number of samples with insufficient sample volume (%)
27 Storage & Transport • Number of damaged sample tubes/containers(%)
28 of samples • Number of samples transported at an inappropriate time (%)
29 • Number of samples transported at inappropriate temperature
30 condition (%)
31
• Number of improperly stored samples (%)
32
33 • Number of samples lost/not-received (%)
34 Suitability of samples • Number of samples with inadequate sample anti-coagulant ratio
35 (%)
36 • Number of samples haemolysed (haematology, chemistry,
37 immunology) (%)
38 • Number of samples clotted (haematology, chemistry) (%)
39 • Number of lipaemic samples (%)
40
• Number of unacceptable samples (microbiology) (%)
41
42
• Number of contaminated blood cultures (%)
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Annals of Clinical Biochemistry

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