Patients detecting procedural errors

BOX 15.3 The invisible work of patients Detecting Procedural Errors... 

Statistics based on distributions of test results from large numbers of patients are useful for detecting systematic errors (shifts and drifts) but are of no value for detecting random errors (increased variability or scatter). They are useful adjuncts to the fundamental control procedures, which use stable control materials, but should not be substituted for them. Patient values include numerous sources of Yaria-tion—demographical, biological, pathological, and preana-lytical (see Chapter 17) —in addition to the analytical variation caused by the analytical method. As a result, individual test values have too much variability to have any utility for QC however, the mean of multiple test values or groups of patients is more stable and therefore maybe useful for control purposes. 

The patient test results are the final product of most laboratory procedures, and the monitoring of these results is the most direct form of QC. Unfortunately, procedures for monitoring results are not very sensitive and have low probabilities for error detection. The most effective procedure is the chnical correlation of test results with other information related to the patient, especially surgical findings, response to therapy, and autopsy data. Less sensitive but easier to implement are comparisons with previous test values and correlation with related test results. The easiest procedure is the comparison of test results with physiological or probabilistic limits. 

A safety culture is key. No matter how advanced the technological system, if humans are involved, errors are inevitable. The key to patient safety and accident prevention is managing the inevitable error by doing two things First, by training to use specific teamwork and communications behaviors, and second to implement safety tools (policy and procedures, protocols, checklists, briefings) to complement behaviors to detect and trap (small) errors before they become a chain creating a serious or even fatal accident (table 1). 

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