When I was in school I learned a lot about science and the laboratory science body of knowledge. The one thing that was emphasized over and over was accuracy and precision. It wasn’t until I secured my first position and started training did I realize just how important those two words were. Not only are we counted on for our accuracy, we are counted on for the repeated accuracy of everything we report to physicians. I have heard some statistics reported that up to 80% of physician decisions on courses of treatment are based on lab results. I really do not get caught up in that number because if you think about it every single value we report is going into a patient’s clinical picture and can affect a decision on a treatment one way or another. So the question always comes up, how do we deal with errors? This question is multifaceted and as a supervisor/administrator we are responsible for much more than just the correction of the error.
I wrote this in my 5 year progress report article but I think it deserves repeating. Everyone makes mistakes, but, it is how you recover and learn from your mistake that is most important. Everyone has had that sinking feeling in their stomach when they learned they have either reported out an incorrect result or have mislabeled a specimen. As a laboratory professional it is our biggest fear and each and every day we sit down at the bench and are expected to be absolutely perfect. Zero errors are a standard that not even the most efficient manufacturers know is possible yet we are expected to perform on this level each and every day. Errors happen to everyone, and when they do it is what happens afterwards that is key to inhibiting that error to occur again. Especially with newer technologists it is important to teach them so that they are able to recover and not make the mistakes again.
The first thing I do when an error is discovered is address it with the technologist. Ask them, “do you remember this sample or this patient? Do you remember what you were doing at the time this error happened?” One thing to watch is how much the technologist can remember. If they cannot remember too many details, were they trying to do too much at once? If they mislabeled did they have a pile of tube and labels while also trying to result specimens? With mislabels I found it helpful for myself to read the name in my head as I was labeling the tube. That way if what I was reading in my head did not match the label underneath I would stop to look. If it is a procedural error why did the technologist deviate from the actual process? Did they learn a shortcut but that shortcut actually increases the chances of error? Going over this with the technologist also will help them with their problem solving skills. Especially with new technologists building problem solving skills is vital to the success or failure of a young technologist. We know humans are not perfect, but when you work in an industry that accepts nothing less, each error made is amplified but also that much more important.
–Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.