scholarly journals A Laboratory Critical Incident and Error Reporting System for Experimental Biomedicine

PLoS Biology ◽  
2016 ◽  
Vol 14 (12) ◽  
pp. e2000705 ◽  
Author(s):  
Ulrich Dirnagl ◽  
Ingo Przesdzing ◽  
Claudia Kurreck ◽  
Sebastian Major
Keyword(s):  
Critical Incident ◽  
Reporting System ◽  
Error Reporting ◽  
Error Reporting System

Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system

Diagnosis ◽  
2017 ◽  
Vol 4 (2) ◽  
pp. 79-86 ◽  
Author(s):  
Veronica Restelli ◽  
Annemarie Taylor ◽  
Douglas Cochrane ◽  
Michael A. Noble
Keyword(s):  
Reporting System ◽  
Learning System ◽  
Medical Laboratory ◽  
Error Reporting ◽  
Canadian Province ◽  
Reporting Systems ◽  
On Line ◽  
Error Reporting System ◽  
Reporting Phase ◽  
Complete Reporting

AbstractBackground:This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System.Methods:The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported.Results:Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences.Conclusions:It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.

scholarly journals Toward a theoretical approach to medical error reporting system research and design

2006 ◽  
Vol 37 (3) ◽  
pp. 283-295 ◽  
Author(s):  
Ben-Tzion Karsh ◽  
Kamisha Hamilton Escoto ◽  
John W. Beasley ◽  
Richard J. Holden
Keyword(s):  
Theoretical Approach ◽  
Medical Error ◽  
Reporting System ◽  
Error Reporting ◽  
System Research ◽  
Error Reporting System ◽  
Research And Design

A Systemwide Approach for Navigating the Dilemma of Oral Factor Xa Inhibitor Interference With Unfractionated Heparin Anti–Factor Xa Concentrations

2020 ◽  
pp. 106002802095627
Author(s):  
Marissa N. Levito ◽  
James C. Coons ◽  
Margaret M. Verrico ◽  
Adrienne Szymkowiak ◽  
Brianna Legler ◽  
...  
Keyword(s):  
Unfractionated Heparin ◽  
Patient Outcomes ◽  
Kansas City ◽  
Reporting System ◽  
Safety Data ◽  
Factor Xa ◽  
Error Reporting ◽  
Factor Xa Inhibitor ◽  
Error Reporting System ◽  
Substantial Uncertainty

Background Oral factor Xa inhibitors are known to significantly increase heparin anti-Xa concentrations, which leads to inaccuracies when monitoring intravenous unfractionated heparin (IV UFH). Guidance for managing this laboratory interference is lacking, creating substantial uncertainty in clinical practice. Objective To describe a strategy used by a large academic institution for managing the controversy of laboratory interference in the setting of oral factor Xa inhibitor use and provide effectiveness and safety data for this approach. Methods In December 2016, a new Heparin IV Direct Oral Anticoagulant (DOAC) Interference PowerPlan (a comprehensive order set) was made available in the electronic health record (Cerner, North Kansas City, MO) throughout the health system. We retrospectively examined 169 patients with events reported in the error reporting system, RISKMASTER, and evaluated reports with and without the use of the PowerPlan. Effectiveness was determined through evaluation of thrombosis. The Naranjo criteria for causality were applied to assess thrombotic events. Results Of 56 events that were reported with apixaban when the PowerPlan was not ordered, 4 (7%) thrombotic events occurred within 7 days of UFH initiation. One out of the 4 events (25%) that occurred when the PowerPlan was not appropriately initiated was considered probable using the Naranjo Scale. Three additional events (75%) were possible using the Naranjo Scale. Conclusion and Relevance The Heparin IV DOAC Interference PowerPlan appears to be conducive to positive patient outcomes when evaluating voluntary reported events and may assist clinicians with managing the therapeutic dilemma of this laboratory interference.

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