CSR error categories

The type of errors recorded in the CSR error log prior to the introduction of the EMR can be grouped in to three broad classes:

1. Errors that are directly linked to patient safety and need to be reported to the Incident Information Management System (IIMS);
2. Errors that are related to the efficiency and effectiveness of laboratory functions;
3. Errors that are attributable or related to the introduction of EMR and associated process changes.

Definitions for each of the error categories are provided in below Table

1. IIMS related categories – the pathology service has a policy that mislabelled, mismatched and unlabelled errors automatically generate an IIMS event due to the fact that these errors are potentially serious and can cause harm to the patient.
Mislabelled specimen	Specimen and test order form are both labelled with the details of the wrong person.
Mismatched specimen	Details on the specimen and test order form are not for the same patient (e.g., specimen labelled with patient A details but test order form labelled with patient B details).
Unlabelled specimen	Specimen with no patient details or no patient label.
2. Efficiency and effectiveness categories – the following categories incorporate errors that are related to the efficiency and effectiveness of laboratory functions.
Accident to specimen	Unable to process specimen due to laboratory accident (e.g., tube broke in centrifuge, inappropriately handled or lost).
Insufficient specimen	Insufficient specimen to perform all the tests.
Leaking specimen	Specimen leaked in transit to the laboratory.
Wrong specimen type	Incorrect specimen type collected (e.g., urine collected instead of blood).
Collection requirement not met	Specimen unable to be processed due to collection requirements not being met (e.g., specimen not collected in correct tube, or not transported on ice or bacterial instead of viral swab collected).
Unlabelled or no request form	Problem with test order form, either unlabelled or none received.
Test set	Incorrect tests entered either by clinician or laboratory (e.g., hepatitis B surface antigen ordered instead of hepatitis B surface antibody to check for immune status).
Patient details problem	Some problem with patient details (e.g., date of birth not entered).
Unsigned request form	Test order form not signed by ordering clinician.
Other	One of several miscellaneous problems (e.g., test cancelled, episode cancelled). In many cases no details were entered into the error log.
3. Errors that are attributable to changed work processes brought on by EMR
EMR test order problem	Error that has been attributed to the electronic medical record (e.g., electronic test order form had a hand written test appended). Hand written amendments to electronic orders can occur for a number of reasons: Clinician forgot to order a test, and instead of entering a new electronic order, the test order was handwritten on an EMR print-out. A clinician requested that a test be added to an original order made by a different clinician. Patient was discharged making it difficult for the clinician to add a test to an existing order. EMR test order problems can also occur when a second or subsequent electronic order is created for a patient and only one specimen is collected. If all test order forms are not sent to the pathology service with the specimen then the pathology service is required to locate the remaining form(s) (since all test order forms must be accounted for). EMR test order problems were sometimes logged for paper orders when the EMR was down or not available.
No specimen received	Test order form received with no specimen.

Table 3 Definitions of error categories in the CSR error log.