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Program

Pathology

Training Level

Resident PGY 2

Institution

Henry Ford Hospital

Abstract

Introduction: To date, there are few papers that characterize the types of errors in microbiology laboratories, and there is scant research demonstrating the effects of interventions on microbiology lab errors. This study aims to categorize the types of culture reporting errors found in a microbiology lab as well as document the error rates before and after interventions designed to reduce errors and eradicate a blame culture. Methods: To increase the amount of errors reported, we moved from a self-reporting system to an automatic reporting system. Errors were categorized into 5 different types: Gram stain (misinterpretations), identification (incorrect analysis), set up labeling (incorrect patient labels on culture plates), procedural (not followed procedures), and miscellaneous (an organism followed criteria for a certain group, but was eventually identified as different). Error rates were tracked according to technologist, and technologists were given real-time feedback by a manager. Furthermore, error rate was monitored in the daily quality management meeting. Technologists attended a year-end review with a manager in order to improve their performance. To maintain these changes, policies were developed to monitor technologist error rate. If a certain number of errors per month is reached, that technologist is required to undergo re-training by either a manager or senior technologist. If a technologist fails to correct any error properly, they are also required to re-train. Results: In 2013, we recorded 0.5 errors per 1000 tests. By 2018, we recorded only 0.1 errors per 1000 tests, an 80% decrease in errors per 1000 tests. The yearly culture volume from 2013 to 2018 increased by 32%, while the yearly error rate went from 0.05% per year to 0.01% per year, a statistically significant decrease (p=0.0007). Conclusion: This study supports the effectiveness of the changes implemented to decrease errors in culture reporting. By tracking and correcting errors in real time, technologists were educated on error prevention. Laboratory safety became a priority to all technologists in addition to managers through daily error prevention and monitoring.

Publication Date

5-2019

Reducing Culture Reporting Errors in the Microbiology Laboratory

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