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Classifying Laboratory Incident Reports to Identify Problems That Jeopardize Patient Safety

Michael L. Astion MD, PhD, Kaveh G. Shojania MD, Tim R. Hamill MD, Sara Kim PhD, Valerie L. Ng MD
DOI: http://dx.doi.org/10.1309/8U5D0MA6MFH2FG19 18-26 First published online: 1 July 2003


We developed a laboratory incident report classification system that can guide reduction of actual and potential adverse events. The system was applied retrospectively to 129 incident reports occurring during a 16-month period. Incidents were classified by type of adverse event (actual or potential), specific and potential patient impact, nature of laboratory involvement, testing phase, and preventability. Of 129 incidents, 95% were potential adverse events. The most common specific impact was delay in receiving test results (85%). The average potential impact was 2.9 (SD, 1.0; median, 3; scale, 1–5). The laboratory alone was responsible for 60% of the incidents; 21% were due solely to problems outside the laboratory’s authority. The laboratory function most frequently implicated in incidents was specimen processing (31%). The preanalytic testing phase was involved in 71% of incidents, the analytic in 18%, and the postanalytic in 11%. The most common preanalytic problem was specimen transportation (16%). The average preventability score was 4.0 (range, 1–5; median, 4; scale, 1–5), and 94 incidents (73%) were preventable (score, 3 or more). Of the 94 preventable incidents, 30% involved cognitive errors, defined as incorrect choices caused by insufficient knowledge, and 73% involved noncognitive errors, defined as inadvertent or unconscious lapses in expected automatic behavior.

Key Words:
  • Incident reports
  • Patient safety
  • Adverse events
  • Laboratory tests
  • Laboratory error