While neither of these studies addressed the question of whether such errors affect patient outcomes, there is indirect evidence that a minor, preventable systems error can have serious consequences. The Quality in Australian Health Care Study 4 showed that a significant number of patient adverse events were related to system errors. These were often errors of omission related to investigations, such as failure to act upon results of findings, or failure to carry out indicated tests. In such cases it is likely that one health care worker's error of omission results from another's error of commission, such as the incorrect delivery of a report. It is likely that most errors occur because of system problems.
Typical examples are poor staff training and non-existent work manuals.
Inadequate computer systems with insufficient internal audit checks and poor or no access to the hospital Master Patient Index and ward information system are the bane of many laboratories' existence. Despite a belief that those in private practice are more skilled at the activities surrounding analysis, the article by Khoury et al. indicates that the problems are widespread in both public and private sectors. The first step in rectifying this situation is to recognise and document that the problems exist. Pathology laboratories should recognise that their professional responsibility encompasses a whole cycle of events, starting with the requesting doctor initiating an investigation necessary for the management of a patient, right through to recognising the significance of the results for the management of the patient. Then, laboratories should be given, and accept, the authority and responsibility necessary to fulfil their professional obligations to both patient and clinician.