C H A P T E R

1
Variation, Errors, and Quality in the
Clinical Laboratory
Jorge Sepulveda
Columbia University Medical Center, New York, New York

INTRODUCTION Failure at any of these steps can result in an erro-

It has been roughly estimated that approximately
70% of all major clinical decisions involve consider-
ation of laboratory results. In addition, approximately
40
94% of all objective health record data are labora-
tory results [1
3]. Undoubtedly, accurate test results
are essential for major clinical decisions involving
disease identification, classification, treatment, and
monitoring. Factors that constitute an accurate labora-
tory result involve more than analytical accuracy and
can be summarized as follows:
1. The right sample was collected on the right patient,
at the correct time, with appropriate patient
preparation.
2. The right technique was used collecting the sample
to avoid contamination with intravenous fluids,
tissue damage, prolonged venous stasis, or
hemolysis.
3. The sample was properly transported to the
laboratory, stored at the right temperature,
processed for analysis, and analyzed in a manner
that avoids artifactual changes in the measured
analyte levels.
4. The analytical assay measured the concentration of
the analyte corresponding to its true level
(compared to a gold standard measurement)
within a clinically acceptable margin of error (the
total acceptable analytical error (TAAE)).
5. The report reaching the clinician contained the
right result, together with interpretative
information, such as a reference range and other
comments, aiding clinicians in the decision-making
process.
neous or misleading laboratory result, sometimes with
adverse outcomes. For example, interferences with
point-of-care glucose testing due to treatment
with maltose-containing fluids have led to failure to
recognize significant hypoglycemia and to mortality or
severe morbidity [4].
ERRORS IN THE CLINICAL
LABORATORY
Errors can occur in all the steps in the laboratory
testing process, and such errors can be classified as
follows:
1. Pre-analytical steps, encompassing the decision to
test, transmission of the order to the laboratory for
analysis, patient preparation and identification,
sample collection, and specimen processing.
2. Analytical assay, which produces a laboratory
result.
3. Post-analytical steps, involving the transmission of
the laboratory data to the clinical provider, who
uses the information for decision making.
Although minimization of analytical errors has
been the main focus of developments in laboratory
medicine, the other steps are more frequent sources of
erroneous results. An analysis indicated that in the
laboratory, pre-analytical errors accounted for 62% of
all errors, with post-analytical representing 23% and
analytical 15% of all laboratory errors [5]. The most
common pre-analytical errors included incorrect order
transmission (at a frequency of approximately 3% of
all orders) and hemolysis (approximately 0.3% of all

Accurate Results in the Clinical Laboratory.

DOI: http://dx.doi.org/10.1016/B978-0-12-415783-5.00001-3 1 2013 Elsevier Inc. All rights reserved.
2 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY
samples) [6]. Other frequent causes of pre-analytical
errors include the following:
Patient identification error
Tube-filling error, empty tubes, missing tubes, or
wrong sample container
Sample contamination or collected from infusion
route
Inadequate sample temperature.
Table 1.1 provides a complete list of errors, includ-
ing pre-analytical, analytical, and post-analytical
errors, that may occur in clinical laboratories.
Particular attention should be paid to patient identifi-
cation because errors in this critical step can have
severe consequences, including fatal outcomes, for
example, due to transfusion reactions. To minimize
identification errors, health care systems are using
point-of-care identification systems, which typically
involve the following:
1. Handheld devices connected to the laboratory
information systems (LIS) that can objectively
identify the patient by scanning a patient-attached
bar code, typically a wrist band.
2. Current laboratory orders can be retrieved from the
LIS.
3. Ideally, collection information, such as correct tube
types, is displayed in the device.
4. Bar-coded labels are printed at the patients side,
minimizing the possibility of misplacing the labels
on the wrong patient samples.
Analytical errors are mostly due to interference or
other unrecognized causes of inaccuracy, whereas
instrument random errors accounted for only 2% of all
laboratory errors in one study [5]. According to that
study, most common post-analytical errors were due to
communication breakdown between the laboratory and
the clinicians, whereas only 1% were due to miscommu-
nication within the laboratory, and 1% of the results had
excessive turnaround time for reporting [5]. Post-
analytical errors due to incorrect transcription of labora-
tory data have been greatly reduced because of the
availability of automated analyzers and bidirectional
interfaces with the LIS [5]. However, transcription errors
and calculation errors remain a major area of concern in
those testing areas without automated interfaces
between the instrument and the LIS. Further develop-
ments to reduce reporting errors and minimize the test-
ing turnaround time include autovalidation of test
results falling within pre-established rule-based para-
meters and systems for automatic paging of critical
results to providers.
When classifying sources of error, it is important to
distinguish between cognitive errors, or mistakes, which
are due to poor knowledge or judgment, and
ACCURATE RESULTS IN THE CLINICAL LABORATORY
noncognitive errors, commonly known as slips and
lapses, due to interruptions in a process that is routine
or relatively automatic. Whereas the first type can be
prevented by increased training, competency evalua-
tion, and process aids such as checklists or cheat
sheets summarizing important steps in a procedure,
noncognitive errors are best addressed by process
improvement and environment re-engineering to mini-
mize distractions and fatigue. Furthermore, it is useful
to classify adverse occurrences as activethat is, the
immediate result of an action by the person perform-
ing a taskor as latent or system errors, which are sys-
tem deficiencies due to poor design or implementation
that enable or amplify active errors. In one study, only
approximately 11% of the errors were cognitive, all in
the pre-analytical phase, and approximately 33% of the
errors were latent [5]. Therefore, the vast majority
of errors are noncognitive slips and lapses perfor-
med by the personnel directly involved in the
process. Importantly, 92% of the pre-analytical, 88% of
analytical, and 14% of post-analytical errors were pre-
ventable. Undoubtedly, human factors, engineering,
and ergonomicsoptimization of systems and process
redesigning to include increased automation and user-
friendly, simple, and rule-based functions, alerts,
barriers, and visual feedbackare more effective than
education and personnel-specific solutions to consis-
tently increase laboratory quality and minimize errors.
Immediate reporting of errors to a database accessi-
ble to all the personnel in the health care system,
followed by automatic alerts to quality management
personnel, is important for accurate tracking and timely
correction of latent errors. In our experience, reporting
is improved by using an online form that includes
checkboxes for the most common types of errors
together with free-text for additional information
(Figure 1.1). Reviewers can subsequently classify errors
as cognitive/noncognitive, latent/active, and internal to
laboratory/internal to institution/external to institution;
determine and classify root causes as involving human
factors (e.g., communication and training or judgment),
software, or physical factors (environment, instrument,
hardware, etc.); and perform outcome analysis.
Outcomes of errors can be classified as follows:
1. Target of error (patient, staff, visitors, or
equipment).
2. Actual outcome on a severity scale (from unnoticed
to fatal) and worst outcome likelihood if error was
not intercepted, because many errors are corrected
before they cause injury. Errors with significant
outcomes or likelihoods of adverse outcomes should
be discussed by quality management staff to
determine appropriate corrective actions and
process improvement initiatives.
 ERRORS IN THE CLINICAL LABORATORY 3
TABLE 1.1 Types of Error in the Clinical Laboratory
Pre-Analytical

TEST ORDERING
Duplicate order Order misinterpreted (test ordered 6 intended test)
Ordering provider not identified Inappropriate/outmoded test ordered
Ordered test not performed (include add-ons) Order not pulled by specimen collector
SAMPLE COLLECTION
Unsuccessful phlebotomy Check-in not performed (in the LIS)

Traumatic phlebotomy Wrong patient preparation (e.g., nonfasting)

Patient complaint about phlebotomy Therapeutic drug monitoring test timing error
SPECIMEN TRANSPORT
Inappropriate sample transport conditions Specimen damaged during transport
Specimen leaked in transit Specimen damaged during centrifugation/analysis
SPECIMEN IDENTIFICATION

Specimen unlabeled Date/time missing

Specimen mislabeled: No name or ID on tube Collectors initials missing
Specimen mislabeled: No name on tube Label illegible
Specimen mislabeled: Incomplete ID on tube Two contradictory labels
Wrong specimen label Overlapping labels
Wrong name on tube Mismatch requisition/label

Wrong ID on tube Specimen information misread by automated reader

Wrong blood type
HIGH PRE-ANALYTICAL TURNAROUND TIME
Delay in receiving specimen in lab STAT not processed urgently
Delay in performing test
SPECIMEN QUALITY

Specimen contaminated with infusion fluid Hemolyzed

Specimen contaminated with microbes Clotted or platelet clumps
Specimen too old for analysis
SPECIMEN CONTAINERS
No specimens received/missing tube Wrong preservative/anticoagulant
Specimen lost in laboratory Insufficient specimen quantity for analysis

Wrong specimen type Tube filling error (too much anticoagulant)

Inappropriate container/tube type Tube filing error (too little anticoagulant)
Wrong tube collection instructions Empty tube
Analytical
High analytical turnaround time Test perform by unauthorized personnel
Instrument caused random error Results discrepant with other clinical or

Instrument malfunction laboratory data

QC failure Testing not completed

(Continued)

ACCURATE RESULTS IN THE CLINICAL LABORATORY

4 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY
TABLE 1.1 (Continued)
Pre-Analytical
QC not completed
Post-Analytical
Report not completed
Delay in reporting results
Critical results not called
Delay in calling critical results
Results reported incorrectly
Results reported incorrectly from outside laboratory
Results reported to wrong provider
OTHER
Proficiency test failure
Product wastage
Product not delivered timely
Product recall
Clearly, efforts to improve accuracy of laboratory
results should encompass all of the steps of the testing
cycle, a concept expressed as total testing process or
brain-to-brain testing loop [7]. Approaches to
achieve error minimization derived from industrial
processes include total quality management (TQM); [8]
lean dynamics and Toyota production systems; [9]
root cause analysis (RCA); [10] health care failure
modes and effects analysis (HFMEA); [11,12] failure
review analysis and corrective action system (FRACAS)
[13]; and Six Sigma [14,15], which aims at minimizing
the variability of products such that the statistical fre-
quency of errors is below 3.4 per million. A detailed
description of these approaches is beyond the scope of
this book, but laboratorians and quality management
specialists should be familiar with these principles for
efficient, high-quality laboratory operation [8].
QUALITY IMPROVEMENT IN THE
CLINICAL LABORATORY
Quality is defined as all the features of a product
that meet the requirements of the customers and the
health care system. Many approaches are used to
improve and ensure the quality of laboratory opera-
tions. The concept of TQM involves a philosophy of
excellence concerned with all aspects of laboratory
operations that impact on the quality of the results.
Specifically, TQM approaches apply a system of statis-
tical process control tools to monitor quality and pro-
ductivity (quality assurance) and encourage efforts to
ACCURATE RESULTS IN THE CLINICAL LABORATORY
Wrong test performed (different from test ordered)
Reported questionable results, detected by laboratory
Reported questionable results, detected by clinician
Failure to append proper comment
Read back not done
Results misinterpreted
Failure to act on results of tests
Employee injury
Safety failure
Environmental failure
Damage to equipment
continuously improve the quality of the products, a
concept known as continuous quality improvement. A
major component of a quality assurance program is
quality control (QC), which involves the use of periodic
measurements of product quality, thresholds for
acceptable performance, and rejection of products that
do not meet acceptability criteria. Most notably, QC is
applied to all clinical laboratory testing processes and
equipment, including testing reagents, analytical
instruments, centrifuges, and refrigerators. Typically,
for each clinical test, external QC materials with
known performance, also known as controls, are run
two or three times daily in parallel with patient speci-
mens. Controls usually have preassigned analyte con-
centrations covering important medical decision levels,
often at low, medium, and high concentrations. Good
laboratory QC practice involves establishment of a
laboratory- and instrument-specific mean and standard
deviation for each lot of each control and also a set of
rules intended to maximize error detection while mini-
mizing false rejections, such as Westgard rules [16].
Another important component of quality assurance for
clinical laboratories is participation in proficiency test-
ing (or external quality assessment programs such as
proficiency surveys sent by the College of American
Pathologists), which involves the sharing of samples
with a large number of other laboratories and compari-
son of the results from each laboratory with its peers,
usually involving reporting of the mean and standard
deviation (SD) of all the laboratories running the same
analyzer/reagent combination. Criteria for QC rules
 QUALITY IMPROVEMENT IN THE CLINICAL LABORATORY 5

FIGURE 1.1 Example of an error reporting form for the clinical laboratory.

ACCURATE RESULTS IN THE CLINICAL LABORATORY

6 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY
Observed True
95%
1 SD
1.65 SD
RE
SE
TE
FIGURE 1.2 Total analytical error (TE) components: random
error (RE), or imprecision, and systematic error (SE), or bias, which
cause the difference between the true value and the measured
value. Random error can increase or decrease the difference from the
true value. Because in a normal distribution, 95% of the observations
are contained within the mean 6 1.65 standard deviations (SD), the
total error will not exceed bias 1 1.65 3 SD in 95% of the
observations.
and proficiency testing acceptability should take into
consideration the concept of total acceptable analytical
error because deviations smaller than the total analyti-
cal errors are unlikely to be clinically significant and
therefore do not need to be detected.
Total analytical error (TAE) is usually considered to
combine the following (Figure 1.2): (1) systematic error
(SE), or bias, as defined by deviation between the aver-
age values obtained from a large series of test results
and an accepted reference or gold standard value, and
(2) random error (RE), or imprecision, represented by
the coefficient of variation of multiple independent test
results obtained under stipulated conditions (CVa). At
the 95% confidence level, the RE is equal to 1.65 times
the CVa for the method; consequently,
TAE 5 1:65 3 CVa 1 bias
Clinical laboratories frequently evaluate imprecision
by performing repeated measurements on control
materials, preferably using runs performed on differ-
ent days (between-day precision), whereas bias (or
trueness) is assessed by comparison with standard ref-
erence materials with assigned values and also by peer
comparison, where either the peer mean or median are
considered the reference values.
One important concept that some clinicians disregard
is that no laboratory measurement is exempt of error;
that is, it is impossible to produce a laboratory result
with 0% bias and 0% imprecision. The role of
ACCURATE RESULTS IN THE CLINICAL LABORATORY
technologic developments, good manufacturing prac-
tices, proficiency testing, and QC is to minimize and
identify the magnitude of the TAE. A practical approach
is to consider the clinically acceptable total analytical
error or TAAE. Clinical acceptability has been defined
by legislation (e.g., the Clinical Laboratory Improvement
Act (CLIA)), by clinical expert opinion, and by scientific
and statistical principles that take into consideration
expected sources of variation. For example, Callum
Fraser proposed that clinically acceptable imprecision,
or random error, should be less than half of the intrain-
dividual biologic variation for the analyte and less than
25% of the total analytical error [17]. The systematic
error, or bias, should be less than 25% of the combined
intraindividual (CVw) and interindividual biological
(CVg) variation:
q
TAAE95% , 1:65 3 0:5 3 CVw 1 0:25 3 CVw 2 1 CVg 2
Tables of intra- and interindividual biological varia-
tion, with corresponding allowable errors, are available
and frequently updated [18]. See Table 1.2 for examples.
Importantly, the allowable errors may be different at spe-
cific medical decision levels because analytical impreci-
sion tends to vary with the analyte concentration, with
higher imprecision at lower levels. Also, biological varia-
tion may be different in the various clinical conditions,
and available databases are starting to incorporate stud-
ies of biologic variation in different diseases [18].
A related concept is the reference change value (RCV),
also called significant change value (SCV)that is, the
variability around a measurement that is a conse-
quence of analytical imprecision, within-subject bio-
logic variability, and the number of repeated tests
performed [17,19,20]. At the 95% confidence level,
RCV can be calculated as follows:
p q
RCV95% 5 1:96 3 2 3 CVa 2 1 CVw 2
Because multiple repeats decrease imprecision
errors, if the change is determined from the mean of
repeated tests, the formula can be modified to take
into consideration the number of repeats in each mea-
surement (n1 and n2) [20]:
r q
2
RCV95% 5 1:96 3 3 CVa 2 1 CVw 2
n1 3 n2
For example, for a serum creatinine measurement
with an analytical imprecision (CVa) of 6.6% and within-
subject biologic variation of 5.3%, the RCV at 95% confi-
dence is 23.5% with one measurement for each sample.
With two measurements for each sample, the RCV is
11.7%. Therefore, a change between two results that does
 CONCLUSIONS 7
TABLE 1.2 Allowable Errors and Reference Change Values for Selected Tests. All Numeric Values are Percentages
Test CVa CVw CVg CLIA TAAE Bio TAAE Allowable Imprecision Allowable Bias RCV95

Amylase 5.3 8.7 28.3 30 14.6 4.4 7.4 28.2

Alanine aminotransferase 2.8 18.0 42.0 20 26.2 9.0 11.4 50.5
Albumin 2.6 3.1 4.2 10 3.9 1.6 1.3 11.2
Alkaline phosphatase 4.2 6.4 24.8 30 11.7 3.2 6.4 21.2
Aspartate aminotransferase 2.2 11.9 17.9 20 15.3 6.0 5.4 33.5
Bilirubin total 10.0 23.8 39.0 20 31.0 11.9 11.4 71.6

Chloride 2.4 1.2 1.5 5 1.5 0.6 0.5 7.4

Cholesterol 2.7 5.4 15.2 10 8.4 2.7 4.0 16.7
Cortisol 5.3 20.9 45.6 25 29.8 10.5 12.5 59.8
Creatine kinase 3.6 22.8 40.0 30 30.3 11.4 11.5 64.0
Creatinine 7.6 6.0 14.7 15 8.9 3.0 4.0 26.8
Glucose 3.4 6.1 6.1 10 7.2 3.0 2.2 19.4

HDL cholesterol 3.3 7.1 19.7 30 11.1 3.6 5.2 21.7

Iron 2.5 26.5 23.2 20 30.7 13.3 8.8 73.8
Lactate dehydrogenase (LDH) 2.5 8.6 14.7 20 11.4 4.3 4.3 24.8
Magnesium 2.8 3.6 6.4 25 4.8 1.8 1.8 12.6
pCO2 1.5 4.8 5.3 8 5.7 2.4 1.8 13.9
Protein, total 2.6 2.7 4.0 10 3.5 1.4 1.2 10.4

Thyroxine (T4) 4.8 4.9 10.9 20 7.1 2.5 3.0 19.0

Triglyceride 3.9 20.9 37.2 25 28.0 10.5 10.7 58.9
Urate 2.9 9.0 17.6 17 12.3 4.5 4.9 26.2
Urea nitrogen 6.2 12.3 18.3 9 15.7 6.2 5.5 38.2

Source: Based on data available at http://www.westgard.com/biodatabase1.htm [18].

CVa, analytical variability in the authors laboratory; CVw, intraindividual variability; CVg, interindividual variability; CLIA TAAE, total allowable analytical error
based on Clinical Laboratory Improvement Act (CLIA); Bio TAAE, q
total allowable analytical error based on interindividual and intraindividual variation.
Allowable imprecision 5 50% of CVw. Allowable bias 5 0:25 3 CVw 2 3 CVg 2 . RCV95, reference change value at 95% confidence based on CVw and CVa.

not exceed the RCV has a greater than 95% probability
that it is due to the combined analytical and intraindivi-
dual biological variation; in other words, the difference
between the two creatinine results (measured without
repeats) should exceed 23.5% to be 95% confident
that the change is due to a pathological condition.
Conversely, for any change in laboratory values, the RCV
formula can be used to calculate the probability that it is
due to analytical and biological variation [17,19,20]. See
Table 1.2 for examples of RCV at the 95% confidence
limit, using published intraindividual variation and the
authors laboratory imprecision. Ideally, future LIS
should integrate available knowledge and patient-
specific information and automatically provide estimates
of expected variation based on the previous formulas to
facilitate interpretation of changes in laboratory values
and guide laboratory staff regarding the meaning of
deviations from expected results. In summary, the use of
TAAE and RCV brings objectivity to error evaluation,
QC and proficiency testing practices, and clinical decision
making based on changes in laboratory values.
CONCLUSIONS
As in other areas of medicine, errors are unavoid-
able in the laboratory. A good understanding of the
sources of error together with a quantitative evaluation
of the clinical significance of the magnitude of the
error, aided by the establishment of limits of accept-
ability based on statistical principles of analytical and
intraindividual biological variation, are critical to
design a quality program to minimize the clinical
impact of errors in the clinical laboratory.

ACCURATE RESULTS IN THE CLINICAL LABORATORY

8 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY
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