Study Finds Some Specialized Lab Tests Pose High Risk for Patient Harm

According to an AHRQ-funded study, some specialized lab tests pose a particularly high risk for patient harm. The study, “A Prospective Tool for Risk Assessment of Sendout Testing,” appeared online March 29 in Clinica Chimica Acta and will also be published in its July 1 print issue. Sendout laboratories—specialty labs used when testing is unavailable at a primary lab—have a high risk for diagnostic errors for many reasons, including increased handoffs, manual processes and complexity associated with rare, low-volume tests. AHRQ’s Kerm Henriksen, Ph.D., is a coauthor of the article, which describes a tool designed to make specialized lab tests safer.

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2014 Jul 1;434:1-5. doi: 10.1016/j.cca.2014.03.028. Epub 2014 Mar 29.

A prospective tool for risk assessment of sendout testing.

Cole B1, Dickerson JA2, Graber ML3, Fantz CR4, Laposata M5, Henriksen K6, Astion ML2, Epner P7.

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Abstract

OBJECTIVE:

Errors associated with laboratory testing can cause significant patient harm. Sendout testing refers to tests sent by a primary lab to a reference lab when testing is unavailable at the primary lab. Sendout testing is particularly high risk for patient harm, due to many factors including increased hand-offs, manual processes, and complexity associated with rare, low-volume tests. No published prospective tools exist for sendout riskassessment.

METHODS:

A novel prospective tool was developed to assess risk of diagnostic errors involving laboratory sendout testing. This tool was successfully piloted at nine sites.

RESULTS:

Marked diversity was noted among survey respondents, particularly in the sections on quality metrics and utilization management. Of note, most sites had committees who managed rules for test ordering, but few places reported enforcing these rules. Only one site claimed to routinely measure the frequency clinicians failed to retrieve test results. An evaluation of the tool indicated that it was both useful and easy to use.

CONCLUSIONS:

This tool could be used by other laboratories to identify the areas of highest risk to patients, which in turn may guide them in focusing their quality improvement efforts and resources.