Question 9.

As a laboratory manager you have been advised that a potential error has occurred leading to an
incorrect result being issued on a patient. Provide a cause-and-effect analysis and produce a fish
bone diagram that describes an error that could lead to an incorrect result being issued.

Table 6. A cause-and-effect analysis describes errors that could lead to an incorrect patient’s result.

Factors Cause Effect

Pre-pre-analytical - Wrong test ordered - Undesirable results related to
- Miscommunication between patient history
doctor and nurse - Messed up results between
different patients
Patient related factors - Medication - Affect assay in the lab, affect
some metabolites in the body
- Biological variation - Affect the rate of metabolite,
metabolism, and hormones
- Haemolysis, lipaemia, jaundice - Interference with many analytical
procedures
Sample collection - Misidentification and information - Mis-labelling sample
of patient
- Inaccurate order of draw - Invalid sample and result
- Inadequate tube - Incomplete result, repeat
component/volume sampling. Inappropriate
anticoagulant ratio, false result.
- Unconsidered site of collection - Contaminated sample, interfere
with analytical assay, false result
Sample handling - Not well-trained employees - Sample is disturbed
- Transport errors such as storage - Can cause haemolysis, some
temperature, transportation delay metabolite is temperature
- Lab processing delay sensitive
- Clotted sample, old sample
Specimen reception - Unlabelled, mis-labelled sample - Delay in testing
and sample - Expired reagent, incorrect assay,
measurement improper calibration, equipment - Delay in testing, invalid result,
malfunction false-positive or false negative
- Undetected failure of quality result
control, sample mix-ups and test
interference
Post-analytical - Incorrect data entry - Incorrect result being issued to
- Incorrect interpretation using patient
improper reference intervals - Cause unnecessary stress to
- Unclear communicating to the patient
clinician