| Summary: | In 2023, the World Health Organization estimates that 1 in every 10 patients experiences harm from unsafe care, with 3 million deaths occurring yearly from the same. Over half the cases of patient harm are preventable and resultant from errors. As 70% of medical decision making involves the laboratory, laboratory medicine is looked upon to improve patient safety. However, laboratory errors are not isolated and unpredictable entities, but rather reflective of the overall healthcare system. Laboratory errors often occur outside the laboratory, as medical testing and procedures are performed by individuals with various levels of quality control training. We describe a case of a specimen labeling error which prolonged a patient’s hospitalization, hindered the medical team’s clinical decision making and increased healthcare cost utilization. We review categories of laboratory errors, outline steps to prevent pre-analytical laboratory errors (defined as those that occur before, during or after specimen collection) and describe metrics to measure quality improvement.
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