Eliminating laboratory errors that cause patient illness and death

In 1999, the Institute of Medicine reported that medical errors, including those that occur in laboratories, may result in as many as 98,000 patient deaths annually in the United States at a cost of $17-29 billion.

To address this issue, the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and the Food and Drug Administration are participating in the Patient Safety Task Force, a federal initiative to monitor and promote patient safety in the United States. An important part of this initiative is to identify and eliminate laboratory errors.

In addition, eliminating laboratory errors is one of "Seven Healthcare Safety Challenges" identified by CDC’s Division of Healthcare Quality Promotion to protect patients, protect healthcare personnel, and promote quality healthcare. For example, the Division is working with clinical microbiology laboratories across the United States to improve their capacity to perform confirmatory testing on certain germs that are resistant to antibiotics. Confirmatory testing is necessary to prevent an incorrect report about the true identification and drug resistance of an organism. An incorrect report can lead a doctor to misdiagnose an illness and recommend the wrong antibiotic.

A recent CDC survey of over 400 clinical microbiology laboratories in the United States showed that 76 percent are aware of the need to perform confirmatory vancomycin testing in Staphylococcus aureus if reduced susceptibility to vancomycin is suspected. This percentage has increased almost 20 percent since 1997 due to CDC’s efforts to provide information and training to clinical laboratories. Additional efforts are underway to ensure that all laboratories perform the correct tests. Please see www.phppo.cdc.gov/dls/master/default.asp.

More information on CDC’s "Seven Healthcare Safety Challenges" to protect patients, protect healthcare personnel, and promote quality healthcare can be found at www.cdc.gov/ncidod/hip/challenges.htm.

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