Studying Frequencies, Types and Causes of Medical Laboratory Associated Errors Using the Electronic Occurrence, Variance and Accident (OVA) Reporting System in Department of Laboratory Medicine and Pathology at Hamad Medical Corporation (HMC)

Abstract

Medical laboratory services are an integral part of healthcare systems that play significant roles in over 70% of medical decisions. Thus, unintentional errors that occur during total testing process (TTP) of laboratory may cause adverse outcomes. Therefore, implementing a system that assists healthcare professional to collect, track and analyze the frequency of incidents is essential for quality improvement. Hamad Medical Corporation (HMC) has implemented OVA system for reporting occurrences, variances and accidents (OVA). Objectives: This study was conducted to (i) determine the types of laboratory associated errors and (ii) to analyze the frequencies and causes of these errors. Design and Methods: The present study, a descriptive retrospective investigation, analyzed 38,814 OVA incidents. The laboratory quality management department provided the incidents recorded by the laboratory information system (LIS) for a three years period from first of January 2017 up to thirty first of December 2019. Incident types were classified into three categories: preanalytical, analytical, post analytical. Descriptive statistical analysis was performed by Microsoft Excel office 365, and frequencies as well as the percentages of incidents were determined. Results: Out of the 38,814 OVA reports, 18,679 (47.6%), 15,347 (40.0%), 4788 (12.4%) incidents occurred in 2017, 2018 and 2019 respectively. The events were grouped into three categories showing 95% for preanalytical, 2% for analytical and 3% for postanalytical categories. The data showed that 91.7% of sample rejection in preanalytical category were due to clotted, hemolysis, and insufficient patient sample volume. In analytical category, quality control issues and equipment errors represent about 82.8% and 17.2% respectively. Finally, most of postanalytical errors were delay in critical results 50.4% and discrepancy 49.6%. Conclusions: This study found that preanalytical category are the major source of reported errors in ova system which accounts for 92%. the main reason for sample rejection were due to sample collection process, which is conducted by nurses and phlebotomist.