310 Outpatient and Inpatient Order Transcription Accuracy of Clinical Lab Order Entry System in Clinical Pathology Lab at Westchester Medical Center. (11th January 2018)

• Record Type: Journal Article
• Authors: Farooq, Taliya; Mashalah, Anas; Budhai, Alexandra; Adem, Patricia
• Is Part Of: American journal of clinical pathology. Volume 149(2018)Supplement 1
• Page Start: S133
• Page End: S133
• Publication Date: 2018-01-11
• Subjects: Diagnosis, Laboratory -- Periodicals; Pathology -- Periodicals; 616.07
• DOI: 10.1093/ajcp/aqx125.309
• Languages: English
• ISSNs: 0002-9173

Abstract

Abstract: Accurate clinical laboratory testing is a critical component of high-quality patient care. The laboratory testing process consists of many steps. Errors or inefficiencies at any step of this testing chain can undermine the entire process and lead to suboptimal patient management. In the Westchester Medical Center (WMC) clinical lab, both CPOE and manual orders entry process are used. According to 10 NYCRR subdivision 58-1.2(c) regarding transcription accuracy, if the laboratory manually transcribes tests into the laboratory information system (LIS), the laboratory must ensure the information is accurately transcribed. The current study was designed to examine transcription accuracy. The specific objectives of this study were to 1) establish total error rate during transcription, 2) to find types of major errors to account for total errors, 3) to find out error rate based on location. The study was conducted using data that included 386 tests (277 outpatients and 109 inpatients) for 5 days that were retrieved from Soft Lab at WMC. Errors were classified into one of four mutually exclusive categories: 1) missed tests, 2) extra tests, 3) cancelled tests, 4) orders without scanned requisitions in Soft Media. Data analysis showed that the total error rate was 47/286 (12.18%). Outpatient error rate was high, 38/277 (13.72%), compared to inpatients error rate, nine of 109 (8.26%). Orders "without scanned documents" and "cancelled orders" account for the majority of errors, 16/47 (34.04%) each. Missed orders were 13/47 (27.6%) total errors. The other types of errors were two of 47 (4.2%). What can be done to reduce error rates? First, the laboratory must have ongoing mechanisms, such as double-keying or supervisory review, to ensure the accuracy of manual entries. Finally, regular audits of the accuracy of transcription into LIS is associated with significantly lower error rates. Based on audit results such as this current study, personnel performing data-entry performance can be subject to training and competency assessment.