A-181 The Effectiveness Module to Reduce Laboratory Error Reporting Rates
Authors: Lee C 
Published: October 2024

Background

In a hospital in central Taiwan, the number of tests conducted in 2022 was 1.88 million, there were 26 cases of laboratory error reports, with an error rate of 14 cases per million. Error reports may lead to diagnostic errors, posing a significant risk to patient safety. Therefore, our team aims to establish a simple and universal module that can be applicable to various laboratory operations to minimize errors.

Methods

Initially, we conducted an analysis of error causes, identifying 25 cases of human error and 1 case of computer system error. Human errors were categorized according to the laboratory process, including 4 specimen identification errors, 3 procedural errors, 9 typing errors, 7 validation of analytical data errors, and 2 instances of failure to communicate issues during handover. The proximate cause of human error was non-compliance with SOPs, and the root cause was inadequate SOPs leading to inconsistent practices. We reviewed the workflow, implemented corrective actions, revised SOPs, and provided training for personnel. Additionally, three important strategies were introduced:

1.High-Frequency Audits: Corrective actions were included in the internal audit checklist, initially increasing the frequency to at least once a month for the first 3 months, followed by at least once every 6 months within the next 6 months. If no further occurrences were noted, audits could be conducted annually or not. Each audit should be completed within 20 minutes to avoid excessive burden, with direct observation of operations and random questioning being the preferred audit methods.

2. Audit deficiencies should be documented: Personnel were requested to conduct cause analysis and improvements. This not only expressed the supervisor's commitment to improvement but also provided an opportunity to discover reasons why countermeasures cannot not be implemented, allowing for strategic adjustments until successful implementation.

3.Case-Based Training: Benchmark cases were developed into teaching materials, and compiled errors regularly for looking for patterns or trends to identity key steps. Make these key steps the focus of your educational training.

Results

In 2023, 1.94 million tests were conducted, there were 4 error reports, with an error rate of 3 cases per million, all were attributed to human error.

In another hospital in southern Taiwan, laboratory error reports were primarily due to human error. From June 2022 to July 2023, a total of 3.46 million tests were conducted, there were 14 error reports and an error rate of 5 cases per million. After implementing the same improvement module from August to December 2023, a total of 1.56 million tests were conducted, there were 2 error reports and an error rate of 2 cases per million, all were attributed to human error.

Conclusions

We applied this improvement module to two hospitals in central and southern Taiwan, resulting in a significant reduction in error rate. The key factors of effectiveness were utilizing high-frequency audits to ensure sustained results, and demonstrating the positive attitude of supervisors during the process. This motivated personnel to demand higher standards from themselves, ultimately showcasing remarkable improvements.