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6th Jun 2017, 07:08 PM
#1
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?
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