Podcast
Questions and Answers
Which of the following is associated with making more lab errors?
Which of the following is associated with making more lab errors?
- High workload
- Inexperienced staff
- Poor training
- Being fatigued (correct)
Which of the following types of work are susceptible to fatigue-associated errors?
Which of the following types of work are susceptible to fatigue-associated errors?
- Laboratory tests
- Data entry
- Patient interaction
- All of the above (correct)
An example of an active error in lab testing is:
An example of an active error in lab testing is:
Mislabeling a patient's specimen
An example of a latent error is:
An example of a latent error is:
Lab management fails to replace an old error-prone analyzer. This is an example of a latent error regarding:
Lab management fails to replace an old error-prone analyzer. This is an example of a latent error regarding:
What is one way to improve the connection between lab workers and patients?
What is one way to improve the connection between lab workers and patients?
An example of improving connection between lab workers and ICU physicians is:
An example of improving connection between lab workers and ICU physicians is:
Which data entry errors are more in need of a strong intervention?
Which data entry errors are more in need of a strong intervention?
Errors that produce false positive lab results can lead to which of the following?
Errors that produce false positive lab results can lead to which of the following?
The most specific and meaningful way to refer to an error in which a patient nearly bled to death due to an INR error is:
The most specific and meaningful way to refer to an error in which a patient nearly bled to death due to an INR error is:
Different types of COVID-19 testing have the same false negative rate.
Different types of COVID-19 testing have the same false negative rate.
Which of the following is a patient safety problem caused by a false negative COVID-19 test?
Which of the following is a patient safety problem caused by a false negative COVID-19 test?
A false negative COVID-19 result can be caused by a mislabeled specimen.
A false negative COVID-19 result can be caused by a mislabeled specimen.
Which of the following is most likely to increase the chance of errors with a manual test method?
Which of the following is most likely to increase the chance of errors with a manual test method?
What is the best advice for a patient with a cholesterol level of 242 mg/dL?
What is the best advice for a patient with a cholesterol level of 242 mg/dL?
Which safety problem can be caused by the failure of the lab to call a critical value?
Which safety problem can be caused by the failure of the lab to call a critical value?
Which of the following is a difficulty associated with critical value policies?
Which of the following is a difficulty associated with critical value policies?
An example of 'Deference to Expertise' in patient safety is:
An example of 'Deference to Expertise' in patient safety is:
When relaying concerns about interpretation of a test result, it is better for a pathologist to speak directly with a care provider than to an administrative assistant who relays the concern.
When relaying concerns about interpretation of a test result, it is better for a pathologist to speak directly with a care provider than to an administrative assistant who relays the concern.
This is an example of what kind of lab error: A genetic test result comes back, but a lab worker forgets to enter the result in the medical record.
This is an example of what kind of lab error: A genetic test result comes back, but a lab worker forgets to enter the result in the medical record.
If a phlebotomist starts noticing conditions like a slight cough and fever, what should he do?
If a phlebotomist starts noticing conditions like a slight cough and fever, what should he do?
A false positive COVID-19 result can be caused by a mislabeled specimen.
A false positive COVID-19 result can be caused by a mislabeled specimen.
Which of the following increases the chance of errors with a barcode-based system for phlebotomy?
Which of the following increases the chance of errors with a barcode-based system for phlebotomy?
ALL abnormal test results are panic and should result in a telephone call from lab personnel to a care provider.
ALL abnormal test results are panic and should result in a telephone call from lab personnel to a care provider.
Who is the most appropriate person to notify with a panic value?
Who is the most appropriate person to notify with a panic value?
An example of a patient safety improvement is:
An example of a patient safety improvement is:
Which of the following problems is preventable?
Which of the following problems is preventable?
Which of the following can provide information helpful for Quality Improvement projects?
Which of the following can provide information helpful for Quality Improvement projects?
Which of the following guarantees that a lab will not commit any errors?
Which of the following guarantees that a lab will not commit any errors?
Who is most likely to successfully troubleshoot a lab instrument in an emergency?
Who is most likely to successfully troubleshoot a lab instrument in an emergency?
Flashcards
Active Errors
Active Errors
Mistakes made at the point of interaction between a person and equipment, like mislabeling a specimen.
Latent Errors
Latent Errors
Hidden organizational flaws that contribute to active errors, such as not installing necessary system interfaces.
Equipment Management Failure
Equipment Management Failure
Failing to replace broken equipment, an example of an organizational error that can lead to mistakes.
Patient Experience Engagement
Patient Experience Engagement
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Prioritizing Error Interventions
Prioritizing Error Interventions
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False Positive Results
False Positive Results
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Distractions in Manual Testing
Distractions in Manual Testing
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Deference to Expertise
Deference to Expertise
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Failure to Report Critical Results
Failure to Report Critical Results
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Post-Analytic Errors
Post-Analytic Errors
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Automation for Error Reduction
Automation for Error Reduction
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Focus on Preventable Problems
Focus on Preventable Problems
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Skilled Troubleshooters
Skilled Troubleshooters
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Ongoing Vigilance
Ongoing Vigilance
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Prioritize Data Entry Errors
Prioritize Data Entry Errors
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False Negative COVID-19 Result
False Negative COVID-19 Result
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Study Notes
Patient Safety and Errors in Lab Testing
- Fatigue increases the likelihood of lab errors among workers.
- Types of work susceptible to fatigue-related errors include all categories of lab work.
- Active errors in lab testing are clear mistakes at the interaction point between human and machines, exemplified by mislabeling a patient’s specimen.
- Latent errors are hidden organizational flaws that lead to active mistakes, such as not installing a necessary interface between lab instruments and Laboratory Information Systems (LIS).
- Equipment management is critical; failing to replace malfunctioning analyzers is considered a latent error.
Improving Connections and Communication
- Engaging lab workers in understanding patient experiences, such as lectures from patients about hospitalizations, enhances quality improvement motivation.
- Direct communication between lab staff and intensive care unit (ICU) physicians helps illustrate the impact of lab tests on patient safety.
Error Impact and Response Strategies
- Data entry errors should be prioritized for interventions based on patient harm; Test B errors caused harm and require stronger corrective actions.
- Errors leading to false positive lab results can have extensive negative consequences, affecting patient treatment and care.
- Clear communication about critical incidents, such as excessive bleeding due to INR errors, is vital for staff awareness and addressing safety concerns.
COVID-19 Testing Insights
- False negative rates can vary across different COVID-19 testing methods.
- A false negative result may facilitate the spread of the virus and can occur due to specimen mislabeling.
Handling Lab Responsibilities
- Distractions in manual testing significantly increase the probability of errors.
- Patients exhibiting high cholesterol levels without symptoms should consult healthcare professionals for further evaluation.
- Failing to report critical test results can delay treatment of life-threatening conditions, highlighting the necessity of stringent panic value protocols.
Improving Safety Protocols
- Deference to Expertise allows skilled technologists to review complex test results effectively.
- Communication of test interpretation concerns is more effective when directly relayed from pathologists to care providers rather than through administrative staff.
- Post-analytic errors include failures to document critical test results in medical records, underscoring the importance of thorough follow-up.
Quality Improvement and Safety Projects
- Effective patient safety improvements include implementing automated systems to reduce human error, such as automated pipetting.
- Quality improvement project focus should be on preventable problems, like recording inaccuracies in test results.
- Continuous learning and data collection from various sources can feed into quality improvement efforts.
General Knowledge on Lab Operations
- There are no guarantees against lab errors; ongoing vigilance is essential.
- The most effective troubleshooters during lab instrument malfunctions are those who frequently use the equipment, highlighting the need for skilled personnel in emergency situations.
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