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Tuesday, August 13, 2013

Transcription errors can maim and kill



I have said on a number of occasions that we run a microbiology proficiency testing program that is predicated on the use of simulation as a learning and challenging process.  If our samples look and act like real samples, then laboratories can use them in a variety of ways to improve process.  A recent survey indicates that we get a lot of support from our participants because of our simulation potential (more on this later).  

But there is one situation in which we do not get a lot of support; indeed some folks get really angry.  We have a committee philosophy and policy that says that our samples have identification with two identifiers and we consider that as the sample’s name.  If a sample is not designated by its proper name, regardless of the work performed, the sample fails.   This genuinely upsets some of the laboratories because they see this as unfair and unreasonable.  

With respect, I disagree.  We refer to improper naming of samples or indeed any incorrect submission of  forms as a post-examination error.  And we take a very aggressive attitude towards post-examination error.

Jump to yesterday’s National Post, one of Canada’s most prestigious national newspapers.  With disappointment we read the story of 4 women who were severely harmed and indeed maimed by the healthcare industry because someone put the wrong breast biopsy report on the wrong patient’s chart, resulting in the wrong person getting the wrong surgery.  In another mix-up the wrong patient ended up with a diagnostic biopsy and the other patient received delayed care because two samples that came to the laboratory got mixed up in accessioning.

One politician’s response, “We are sooo sorry“, and another was “Well, healthcare is run by people and sometimes people make mistakes”.  Another response, “Well, we were planning to put in a bar-code system that will reduce the chance of this happening again”.

Look, I have read James Reason and his books on risk and error, and I get it, sometimes people screw up;  sometimes we call them slips, sometimes we can them distractions, and sometimes we call them mistakes.  Most of the time, they are invisible or they cause at most some inconvenience.  But sometimes they don’t.  Sometime, especially in healthcare, they can hurt people.  In some industries fail-safe check systems are introduced to prevent them from happening at critical times.  In some industries they talk about fail-safe, and in others they don’t even bother talking about them.  

In the past I have talked about the casualness that exists in healthcare when it comes to post-examination error, in particular when it affects confidentiality.  [see: http://www.medicallaboratoryquality.com/2013/08/confidentiality-and-laboratory-error.html ]  If we just accept slips to occur without acknowledging their consequences, then we allow folks to not worry about them.  And that can lead to really bad outcomes.

And at that point, the problem is no longer slips and inattention, it is failure to develop policies and processes to protect patients.

So CMPT will continue to consider transcription errors as part of the proficiency testing exercise and will continue to view them as Major Errors.  

And so should you.

PS:
Our POLQM Quality Conference is coming along really well.  Hope to see you in Vancouver.  If you come, let me know that you are a sometimes reader of MMLQR.

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