Naslov
Risk assessment for manual handling of hemolyzed samples on patient safety

Autori
Miler, Marijana ; Nikolac, Nora ; Lukšić, Ana Helena ; Bakliža, Ana ; Dukić, Lora ; Šimundić, Ana-Maria

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, sažetak, znanstveni

Izvornik
Biochemia Medica / Šimundić, Ana-Maria - Zagreb : Hrvatsko društvo za medicinsku biokemiju i laboratorijsku medicinu (HDMBLM), 2015, S125-S126

Skup
8. kongres Hrvatskog društva za medicinsku biokemiju i laboratorijsku medicinu s međunarodnim sudjelovanjem

Mjesto i datum
Rijeka, Hrvatska, 22.09.2015. - 26.09.2015

Vrsta sudjelovanja
Poster

Vrsta recenzije
Domaća recenzija

Ključne riječi
preanalytical phase ; laboratory error ; interferences ; hemolysis ; risk analysis

Sažetak
Introduction: Manual handling of hemolyzed samples is not standardized and is error prone. This could lead to significant impact on clinical decision and patient safety. We aimed to assess the risk for patient safety caused by laboratory errors due to manual handling of hemolyzed samples. Materials and Methods: All laboratory samples (N=3185) were visually assessed for hemolysis by one person in the period of one week. In this retrospective analysis 25 emergency tests were included. Hemolysis was assessed by comparison with a color chart and all samples with concentration of free hemoglobin >0.5 g/L were considered hemolyzed. Data were retrospectively obtained from laboratory information system. Correct way of handling the results (results reported or sample rejected) was determined for each test. Risk assessment was done according to ISO 14971 standard with 5 risk categories (S1=minimum impact, S2=additional sampling, S3=delayed diagnosis, S4=inappropriate therapy, S5=possible fatal outcome) and frequencies of occurrence (O1<10%, O2=10-20%, O3=21-50%, O4=51-75%, O5=76-100%). Critical categories were defined as those with the highest combination of risk and occurrence rate. For these tests some immediate corrective measures are necessary to improve the patient safety. Results: In the period of one week emergency laboratory has received 2518 test requests in 495 hemolyzed samples (15.5%). Even 780 results (31%) were incorrectly reported accounting for 4.8% of the total test volume. The majority (67%) of erroneously reported results was made available to physicians in spite of being hemolysed. Even 33% of samples were unnecessarily rejected. Tests in critical category with the highest combination of risk and occurrence rate were troponin T (S5, O5), potassium (S5, O4) and total bilirubin (S4, O4). Conclusion: Manual handling with hemolyzed samples may lead to risk of errors in reporting results for troponin T, potassium and total bilirubin which may impact clinical decision and patient outcome.

Izvorni jezik
Engleski

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