Posted by Sten Westgard, MS
In the December 2011 issue of Point of Care journal, an interesting study was published:
Preanalytical Errors in Point-of-Care Testing: Auditing Error of Patient Identification in the Use of Blood Gas Analyzers, Natalie A Smith, David G Housley, Danielle B. Freedman, Point of Care, Volume 10: Number 4, December 2011.
The study looked at patient identification errors on a blood gas analyzer in various departments in a hospital. Bearing in mind that this is just one type of pre-analytical error, what do you think the rate was? Given around 100,000 tests, what would you guess as the number of defects?
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Fresh on the heels of a study about error rates in a Romanian hospital, now we've got a new study about pre-analytical error rates at a Chinese hospital:
Corrected reports in laboratory medicine in a Chinese University hospital for 3 years, Liu X, Jiang Y, Zeng R, Zaho H, Clin Chem Lab Med 2014;52(4):e57-e59
Want to guess how many errors this lab experienced out of 1.1 million test reports in 2012?
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
We've all heard the infamous quote now over a decade and a half old: that US hospitals kill between roughly 40,000 and 90,000 patients each year. This was an estimate courtesy of the Institute of Medicine report "To Err Is Human" which made the dire performance of hospitals knowledge that even the general public could understand.
But more recently, studies have been tracking the adverse event rates much more closely. A recent NEJM paper followed four conditions from 2005 to 2011.
Of these four conditions, which do you think has the best Sigma performance when it comes to the occurrence of adverse events?
A. Acute Myocardial Infarction (AMI)
B. Congestive Heart Failure
C. Pneumonia
D. (other) Conditions Requiring Surgery
The answer, after the jump...
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Posted by Sten Westgard, MS
In a recent issue of CCLM, an interesting opinion paper reported on a pilot study of the quality of UK laboratories.
Given 5,812 QC data points on 5 different platforms in 9 different laboratories measured over 6 months, and a quality goal of 7.0% how many of those laboratories do you think achieved 5-Sigma quality?
- 100%
- 75%
- 50%
- 25%
- less than 25%
The answer, after the jump...
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Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
It's almost mandatory that any presentation or report discussing patient safety references the landmark IOM report of 2000: To Err is Human - Building a Safer Health System. The takeaway quote from this report is that US hospitals were causing 44,000 to 98,000 deaths that were otherwise preventable. That is, hospitals were causing tens of thousands of avoidable deaths.
A recent paper has attempted to revise that estimate, focusing on Preventable Adverse Events (PAEs) that contributed to the death of patients. Can you guess how lethal US hospitals are now?
- 4,000 to 10,000 PAEs per year
- 44,000 to 98,0000 PAEs per year
- 100,000 to 200,000 PAEs per year
- 210,000 to 440,000 PAEs per year
The answer, after the jump...
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Posted by Sten Westgard, MS
A lot of interesting studies coming out this month, unfortunately none of them with encouraging news about the US healthcare system.
The latest, from Sunil Eappen, MD, Atul Gawande, MD et al, Relationship Between Occurence of Surgical Complications and Hospital Finances, JAMA, April 17, 2013, Vol. 309, No. 15 1599-1606
Take a guess: do US hospitals make more money when things go wrong, or less?
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Posted by Sten Westgard, MS
Recently, the journal In Vitro Diagnostics Global News a publication of CGI KK and in association with CAP Today, has begun publishing a series of translations of Westgard articles into Japanese:
The title of the series is Think QC Again, an important message regardless of language or country.
Posted by Sten Westgard, MS
In the recent issue of Clinical Chemistry, an editorial reviews the current state of Vitamin D testing: "There is common agreement that 25-OHD is a 'difficult' analyte."
25-Hydroxyvitamin D: A Difficult Analyte, Graham D. Carter, Clin Chem 58:3; 486-488 (2012).
At the same time, the editorial notes that marked process is being made:
"Nevertheless, results submitted to the international Vitamin D External Quality Assessment (DEQAS) have shown a gradual reduction in interlaboratory imprecision (CV) in recent years - from >30% in 1995 to 15% in 2011."
The question is, is that reduction in imprecision good enough? Or is the quality required by Vitamin D still too "difficult"?
More after the jump...
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Posted by Sten Westgard, MS
So we all know that Risk Analysis is coming to laboratories in the US. (click here if this is news to you). But Risk Analysis, particularly the FMEA technique (Failure Mode and Effects Analysis), is not new to healthcare. Outside the laboratory, plenty of healthcare practitioners have been performing FMEA.
So what do they think about this technique? Try and guess which one of these responses is from a someone in healthcare:
- "The jury's still out on the FMEA process because... has anybody evaluated FMEA as a tool for analysing risk? And it turns out there isn't... well why are we doing this process?... When all it is doing is bringing a few things to the surface, which is no bad thing, but it's not a validated process."
- "...Forget FMEA. It doesn't really work effectively, I don't think, and the scores are a hindrance rather than anything else, year... We wasted a lot of time on FMEA before we realized, this isn't actually working. Yeah, because I think you can get caught up on just the score, that's the thing."
- "The scoring in the FMEA teams need to be the same people, if you change half way through because of the highly subjective interpretation things change dramatically."
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
Posted by Sten Westgard, MS
[Hat-tip to the AACC Point-of-Care listserve, which first posted a notice about this article]
The Pennsylvania Patient Safety Advisory has a regular electronic newsletter highlighting new science and studies about healthcare safety. Their December 2011 issue has a particularly interesting article for laboratory testing:
Point-of-Care Technology: Glucose Meter's Role in Patient Care, Lea Anne Gardner, PhD, RN, Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority.
This review examined more than 1,300 reports of glucose-meter problems from the Pennsyvlania reporting system database from 2004 to 2011. Of those reports, 71 near-miss or adverse event reports occurred. Most intriguing are the report excerpts directly quoted in the study. Of those reports, 72% of the near-miss or adverse events occurred with high-blood glucose results. That is, where the glucose meter had a sudden high value that may or may not have been reflective of the actual patient's clinical state. For example:
"A patient's blood sugar was checked using a [glucose meter]. The lunchtime result was 517. A [blood glucose test] was [immediately] retaken to check for accuracy, and the result was greater than 600. A blood [laboratory] test was conducted per protocol, and the [lab] glucose [result] was 136..."
What do you think happened next?
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Posted by Sten Westgard, MS
A recent Clinical Laboratory Strategies article:Anchoring POC Quality in Clinical Decision-Making and the related study: Novel analysis of clinically relevant diagnostic errors in point-of-care devices, KM Shermock, MB Streiff, BL Pinto, P Kraus, an dPJ Pronovost, (J Thromb Haemost 2011;9:1769-1775) have an interesting observation about the use of the correlation coefficient to accept method performance.
They looked at Hemochron POC devices, analyzing 1518 paired INRs. The correlation between the POC and laboratory measurements ranged between 0.84 and 0.91.
The authors stated, "Traditional, quarterly, quality assurance studies emphasize correlation analysis." So this study has good news, right?
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