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Thread: Wrong GS result matched to patient - is the system still suitable for EI ?

  1. #1
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    Wrong GS result matched to patient - is the system still suitable for EI ?

    We have recently been made aware that, under specific circumstances (e.g. a slow network) the wrong result can be transferred to a patient. The LIMS provider is unable to perform an automated review of the results and it isn't clear if any/many sites have seen this error.
    We therefore performed an audit of our WBITs to see whether all of these were genuine, or if we could find evidence for this computer glitch in our system too. (We have a two sample rule)
    So far we have already found one LIMS error (yet to check pre-2016 data) were the patient's first result wasn't actually a wrong blood in tube but the wrong blood group had been transferred (the correct result was received from the analyser). This was picked up as a WBIT but it is also possible for the same wrong result, by sheer bad luck, to be transferred to a patient on multiple occasions. The more history a patient has the less likely it is that the same error occurred again and again...
    We have for now introduced a manual checking process for all our results against the results displayed in the patient's demographics.
    The question is, based on the fact that we are now double checking an automated system manually, should we declare the system non-compliant with EI guidelines and in effect stop the use of remote issue fridges too?

  2. #2
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    Yes it would be non-compliant.
    The corrective action is for the LIMS provider to sort this out as a priority, this is unacceptable. It is probably also Med Devices reportable.
    The LIMS rules governing remote issue could be affected.
    Also, the impact of results being transmitted from other Pathology areas- how do you know if Haem and Biochem results are going across to the correct records?

    Good luck!

  3. #3
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    To be honest what has surprised me the most is that there wasn't an outcry by the wider user group of the system to declare it non-EI compliant. As far as I am aware nobody has taken the decision to stop EI and the supplier doesn't regard the LIMS glitch as a deal-breaker in terms of EI as a different set of rules is checking patient's history etc at the time of product issue. Or maybe there just aren't as many users out there who use the system and use EI?

    Btw we do not edit the transmitted results, we just check that there was no glitch during the transfer and the correct result is displayed.

    There is no impact on any other Pathology results as they all go via a different interface, it's just the BT module that is affected.
    Last edited by Barbara; 20th Jun 2017 at 03:21 PM.

  4. #4
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    I suppose as you have a 2 sample rule, and have only come across this once, then it is about being realistic on detecting the error. It would be far riskier to have to cross-match everything and the impact this would have on staff, stock holding etc would mean introducing other errors. I still don't understand how the result can be transferred to the incorrect LIMS record if the transfer between the analyser and LIMS requires a full lab number and possibly other identifier match- very difficult to replicate and investigate properly unless the supplier can provide more details.

    Perhaps the wider user group has not come across this error yet as your lab probably tests far more samples?

  5. #5
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    As you are probably aware there are many IT related reports submitted to SHOT where there are weaknessses in IT systems and we are alarmed at what you describe in this post. We would like to discuss this issue with you, to further understand the situation. Please contact Hema Mistry, Laboratory Incident Specialist at hema.mistry@shot.nhsbt.nhs.uk or 0161 423 4235

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