Statement of problem: The test menu in the clinical laboratory now includes thousands of assays, and inappropriate selection of coagulation tests is a frequent source of error.
Description of the intervention or program: Beginning July 2010, our hospital instituted a coagulation diagnostic management team (DMT) to provide 1) expert driven, patient specific interpretations of test results in the context of the clinical situation and 2) panel testing for comprehensive evaluation for specific disorders resulting in bleeding or thrombosis. In order to assess impact on patient care, a one-week prospective clinical audit monitored all testing in the esoteric coagulation laboratory. All communications, including corrections of test selection, were recorded. After 30 days, a retrospective review of the medical records was performed for assay results, interpretation, and impact on patient care.
Findings to date: Interpretative reports submitted for 53 patient cases, including more than 250 separate coagulation assays, were reviewed in the first several weeks of DMT activity and before testing panels were widely used by clinicians. Seventy percent of cases were being managed by specialists outside the field of hematology. The most common clinical indications for testing included evaluation for a hereditary causes of thrombosis (30.2%), followed by antiphospholipid antibodies (28.3%), von Willebrand disease (17.0%), and disorders of platelet function (9.4%). Thirty-three errors were identified in 31 cases (63%) while 22 cases had no detectable error. Errors in test selection (34%) were most common and usually attributable to omission of a single assay of part of a panel. Errors in patient follow-up were also common. At the 30 day follow-up time point, 23% of cases had abnormal results and the patient’s medical record contained no comment on the interpretation or plan for follow-up, or an evidence-based recommended action in the interpretation had not been performed. Sample collection errors were not uncommon (7.5%). Of the errors noted before the performance of assays (21 out of 33), 16 were recognized and corrected by the DMT prior to release of results (76%), including 10 cases of test selection error. In two of these cases, the omitted assay was critical for diagnosis.
Lessons learned: Expert interpretive reports through diagnostic management teams can reduce errors and increase patient safety. The error rate of test selection is high and can be reduced via laboratory monitoring and panel based testing.