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Journal of Clinical Microbiology, May 2005, p. 2188-2193, Vol. 43, No. 5
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.5.2188-2193.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

Clinical Impact Associated with Corrected Results in Clinical Microbiology Testing

Shan Yuan,¹ Michael L. Astion,^1* Jeff Schapiro,^1,2, and Ajit P. Limaye^1,2

Department of Laboratory Medicine,¹ Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington²

Received 29 September 2004/ Returned for modification 13 November 2004/ Accepted 31 December 2004

We developed a strategy to determine the clinical impact associated with errors in clinical microbiology testing. Over a 9-month period, we used a sequential three-stage method to prospectively evaluate 480 consecutive corrected microbiology laboratory reports. The three stages were physician review of the corrected report, medical record review, and interview with the clinician(s) taking care of the patient. Of the 480 corrected reports, 301 (62.7%) were ruled out for significant clinical impact by physician review and an additional 25 cases (5.2%) were ruled out for clinical impact by medical record review. This left 154 cases (32.1%) that required clinician interview to determine clinical impact. The clinician interview revealed that 32 (6.7%) of the corrected reports were associated with adverse clinical impact. Of these 32 cases, 19 (59.4%) involved delayed therapy, 8 (25.0%) involved unnecessary therapy, 8 (25.0%) were associated with inappropriate therapy, and 4 (12.5%) were associated with an increased level of care. The laboratory was entirely responsible for the error in 28 (87.5%) of the 32 cases and partially responsible in the other 4 cases (12.5%). Twenty-six (81.3%) of the 32 cases involved potentially preventable analytic errors that were due to lack of knowledge (cognitive error). In summary, we used evaluation of corrected reports to identify laboratory errors with adverse clinical impact, and most of the errors were amenable to laboratory-based interventions. Our method has the potential to be implemented in other laboratory settings to identify and characterize errors that impact patient safety.

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* Corresponding author. Mailing address: Department of Laboratory Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-7110. Phone: (206) 598-8400. Fax: (206) 598-6189. E-mail: mastion{at}u.washington.edu.

Present address: Kaiser-Permanente, Vallejo Medical Center, 975 Sereno Drive, Vallejo, CA 94589.

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Journal of Clinical Microbiology, May 2005, p. 2188-2193, Vol. 43, No. 5
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.5.2188-2193.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

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