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Related Experiment Videos

Laboratory blunders revisited

R Lapworth1, T K Teal

  • 1Department of Clinical Chemistry, William Harvey Hospital, Ashford, Kent, UK.

Annals of Clinical Biochemistry
|January 1, 1994
PubMed
Summary
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Clinical chemistry blunders occur at a low rate (<0.1%). Most errors are caught internally, but a review of these laboratory blunders aids performance improvement.

Area of Science:

  • Clinical Chemistry
  • Laboratory Medicine
  • Healthcare Quality Improvement

Background:

  • Laboratory errors, termed blunders, can impact patient care.
  • Understanding the frequency and source of these errors is crucial for quality assurance.

Purpose of the Study:

  • To categorize and analyze blunders in clinical chemistry departments over a one-year period.
  • To identify the types and detection stages of laboratory errors.

Main Methods:

  • A retrospective analysis of blunders in two health districts over 12 months.
  • Blunders were defined as incidents leading to incorrect results, categorized by type and detection stage.

Main Results:

  • A total of 120 blunders were recorded, representing a rate below 0.1% of requests.

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  • 44% of blunders were detected at the final laboratory checking stage.
  • Errors were distributed across booking-in (36), analysis (38), and reporting (35) stages.

    • Conclusions:

    • Laboratory blunders occur infrequently but require systematic review.
    • Internal detection mechanisms are effective, but external detection also plays a role.
    • Formal review of laboratory blunders is essential for enhancing overall departmental performance.