Detection of Pre-Analytical Laboratory Testing Errors: Leads and Lessons for Patient Safety

Introduction

The Institute of Medicine’s report (IOM’s) 1999, To Err is Human: Building a Safer Health System, about medical errors in the United States (U.S), was a driver for the creation of a national agenda to address massive costs in terms of life lost, injury, and the financial burden of medical care required as the result of clinical mistakes, and ultimately the ever increasing burden of medical indemnity. Widespread curiosity about the consequences of medical errors emerged in 1999 when the Institute of Medicine unexpectedly reported that medical errors accounted for up to 98,000 deaths in US hospitals each year. One of the outcomes of the magnitude of these deaths was that they exceeded the annual deaths as the results of car accidents, breast cancer, or Acquired Immunodeficiency Syndrome (AIDS), although preventative measures had been highlighted for several years. The IOM report estimated that medical errors cost the U.S. $17-$29 billion a year, and called for huge changes to the health-care system to improve patient safety (Kohn, Corrigan & Donaldson, 1999). The IOM followed their 1999 report with several other reports, including a 2001 report titled, Crossing the Quality Chasm: A New Health System for the 21st Century. This report was prepared by the IOM committee on quality of the health care in the United States. As the result of rapid changes, the country’s health care delivery system has developed better ability to translate knowledge into practice and applies new technology for patient safety. Crossing the Quality Chasm concentrates more extensively on how the health system care can be transformed and improves the delivery of care. Towards this goal, the committee presented several strategies and action plans for the next years (Institute of Medicine, 2001).