میزان و علل خطاهای بعد از آزمایش درآزمایشگاه مرکز طبی کودکان

  Background: Laboratory tests are used to diagnose diseases, monitor its progress and response to treatment. So the goal of the laboratory medicine is reporting accurate and on time test results. The aim of this study was to evaluate rate and causes of post-analytical errors in the Clinical Laboratory of Children’s Medical Center. We especially focused on 1) delay in reporting test results and 2) inaccuracy of test results.   Methods: This descriptive study was conducted in Children’s Medical Center in 2008. Any complaint related to accurate reporting and on time test results from inpatients and outpatients, physicians and wards during 3 months period were registered. The reasons were investigated then recorded in predesigned forms data were analysed with SPSS version 15, Chi square and Fischer’s tests.   Results : A total of 375 of 425 complaints were related to delay in reporting test results. We also recorded 50 cases of erroneous result complaints. Also 72% of delayed reports and 34% of complaints of unaccepted results were caused in post-analytical phase (i.e. after test was performed). “Failure to input the results in computer” was the main reason (37%). “Lost results “(25%) and transcription error (22.6%), “absence of laboratory request form” (9.8%) and “wrong method of filing” (4.2%) were the other observed causes. Microbiology, hematology and clinical chemistry were departments with the highest rate of complaints whereas urine culture, CBC and biochemistry tests were the most frequent problematic tests. The rate of complaints was 1:108 patients or 1:541 tests, and 4.8% of results were not reported in timely manner.   Conclusion: Our findings revealed that the source of most of the errors related to reporting test results were in post-analytical phases. Therefore along with continuing the educational programme, and improvement of automation, it seems necessary to add periodic evaluation and investigation of errors to benchmarks programmes, especially in reporting test result processes, in order to provide error free service to physician and their patients. Cooperation with the clinicians and the other personnel outside the laboratory is also important for error reduction.