Tag Archives: laboratory errors

“The paradox of the error free laboratory…”

A lot of people strive to make their microbiology laboratory “error free”. Whilst this could be said to be an admirable goal, maybe we need to think about what we wish for a little further..

A progressive laboratory by definition is going to make errors. You cannot introduce a new software system into the lab without making mistakes. You cannot develop a new assay without going through a teething process. You cannot develop an electronic requesting system without going through a lot of trial and error first.

Making changes to a laboratory are necessary so that the systems are of better quality and efficiency in the long-term. I would be concerned about the laboratory that believed that mistakes should be avoided at all costs.

Of course we should try and anticipate where errors might happen, as well as analysing ones that have occurred in order to reduce the chances of them happening again. Pilots, validations and quality control processes also reduce the chances of any potential errors occurring or impacting on the patient.

The same applies for complaints from laboratory users. When introducing new laboratory systems and technologies, there will always be a few users who are unhappy with the change, for various reasons, not necessarily microbiological… Part of our job is to educate users about the reasons for introducing new laboratory systems and making their expectations of the process realistic.

So maybe the next time your boss comes to you and says “Congratulations, so far this year we have had no errors, and no complaints from laboratory users”, maybe the response should be “So what are we doing wrong?….”

Michael

p.s. Note that within the website I am writing a short personal blog on my experiences and observations in Paris. Click here to access. Please feel free to have a read from time to time.

p.p.s Note that that this website www.microbiologymatters.com is specially adapted for use on smart phones. Let me know if you have any problems.

 

“Eradicating Blame Culture in the Laboratory”

I remember working as a junior doctor in an ED department in a rough and tough area of East Glasgow. The roster was arduous, 60 hrs a week, 1 in 4 nightshifts. On our first day, the consultant sat us down and talked to us about the job. He told us that in seeing 40-50 patients a shift we would be making so many decisions that we were bound to make mistakes (and we did), but as long as he was in charge, and we were not acting maliciously, he would back us up to the hilt in the case of any complaints (and he did). He drummed into us the importance of working as a team and implicitly trusting one another’s work. I never once heard him ask “Who did that?” His whole philosophy relaxed us, helped us to work as a team, and made a tough job that bit easier..

In the laboratory setting we also have to make a lot of decisions every day, and of course mistakes will be made. When they are made it is important to first of all ask “How can we stop this happening again”, before even considering “Who?”.

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Any individual feedback on mistakes should always primarily focus on the cause of the error, not the error itself.

There will always be the occasional case, ie that involving very serious errors or non-conformities where the “Who?” question needs to be addressed formally, but in the majority of cases, the act of fixing the system makes the “Who” question of academic nature only.

I always aspire to act like my old ED consultant (sadly no longer with us), and try to resist that primeval/gut instinct to ask “Who” when an error is reported to me. I don’t always manage it but I am improving slowly as I get older….

Michael