The frequency and potential clinical impact of non-analytical errors in the RCPA Microbiology QAP 1987-2008.

Background: Reliable reporting of laboratory results is an important component in the diagnosis and management of infectious diseases. We investigated the frequency of pre- and post-analytical errors by participants in the Royal College of Pathologists of Australasia (RCPA) Microbiology Quality Assurance Program (MQAP).

Methods: We retrospectively reviewed MQAP data 1987-1991 and 2004-2008. Pre-analytical error rates were based on participants' detection rate of clerical error for patient name and identification number for the given test item. Fictitious errors were defined as the reporting of a labelling error when in fact there was no discrepancy. Post-analytical error rates were based on clear transcription errors resulting in the test result being incorrectly assigned to another test item.

Findings: When there was one clerical error 10.6% of participants failed to report it. When there were two errors 5.3% failed to report either error and 8.8% only reported one error. Fictitious errors were reported by 1.1% of participants. Pre-analytical errors have not decreased over time. Of the 106 items where direct transposition errors were possible, 73 (69%) had at least one participant who transposed the results. During 2004-2008 transposition of mycobacterial smear and culture results occurred in 18% and 16% of participants, respectively.

Interpretations: Pre- and post-analytical errors are not rare amongst participants in the RCPA MQAP. These non-analytical components of the testing pathway require improvement because of their potential to adversely affect patient care.