It was 5 years ago this month that the Institute of Medicine (IOM) released a report titled “To Err is Human: Building a Safer Health System.” According to the report, as many as 98,000 Americans die each year as a result of preventable medical errors. The report went on to say that death due to medical errors is higher than death as a result of motor vehicle accidents, breast cancer, or AIDS.
As a result of the IOM report and heightened public awareness about medical errors, much has been done to reduce mistakes and deficiencies in hospitals. However, there are still alarming reports of failures, including in the area of laboratory testing. For example, earlier this year, we learned that the laboratory at Maryland General Hospital in Baltimore released HIV and hepatitis test results in spite of indications that the results might be inaccurate. A former employee complained about faulty lab equipment, and a subsequent inspection by the State of Maryland revealed that there was improper alteration of quality-control results. Moreover, the former employee claims that the malfunctioning instrument, which affected the reliability of the test results, caused her to be infected with HIV when blood was sprayed during a testing procedure.
This incident and others remind us of how critical it is to have precise instrumentation and personal protective equipment, to properly prepare patients, to monitor the way samples are handled, and to accurately interpret test results. In short, there must be great attention to detail in every step of the testing process. While some argue that analytical errors are no longer a major problem and that most laboratory errors occur before and after testing, laboratorians and other health care professionals must work together to find ways to eliminate errors in every phase of testing, including preanalytical and postanalytical processes.
Maryland General Hospital has since corrected many of its problems by bringing in an outside consultant to run the lab and hiring more laboratory staff. It has also retested many of those who had HIV and hepatitis tests at the lab and found that most of the original results were accurate despite the equipment problems. However, the lesson is clear. While it is true that to err is human, the stakes are high when test results can be a matter of life or death.
In keeping with the safety theme, be sure to read our profile (page 32) of a new patient identification and tracking system from Olympus. You should also read about the safety features available on the new Peloris tissue processor from Vision BioSystems (page 30).
Have a great month, and be safe.
Carol Andrews
Editor
[email protected]
