Defining errors into clear categories can help the process improvement team pinpoint likely root causes for each kind of error which may appear within a process. When this process is applied to histology errors, most examples can be included within a few error categories.
Clerical Errors- These are defined as a failure in information accuracy in a process that disrupts the maintenance of identifying, unique information of patient or specimen. The specimen accession process is an intrinsic component of grossing and specimen quality assurance. The most serious errors in specimen identification frequently occur during accessioning. When we place clerical errors into root cause analysis we can propose the following potential root causes as being a result of technical, organizational of human failures. Possible process sources for many clerical errors are simple inaccuracy in adding or modifying patient or specimen data into the laboratory information system. This can be contributed to by poorly designed computer interfaces, or failures to utilize opportunities for technology tools for ensuring and checking accuracy such as bar-code verification.
- These errors are defined as a failure to complete or all process steps necessary or inaccurate completion not compliant with procedure/ protocol resulting in erroneous, inaccurate or incorrect results. This root cause often results from a lack of standardization, or a lack of clear procedures or experience. Some possible root causes for these kind of defects may be a failure to recognize instrument malfunction, skipping essential steps in manual technical procedures, or application of the wrong corrective steps. Process problems are often improved by increasing standardization, improving training and experience level.
Technical Errors- These errors are defined as afailure to apply correct/appropriate technical judgment to adjust technique as needed to produce the desired outcome from the performance of a technical process. Technical and process errors are closely related. Technical errors may depend more closely however on a gap in understanding of technical theory which may make error detection and process adjustments more difficult to execute. Technical errors are related to simple human errors, but are most correctable by increased instruction in technical theory, and education or training.
Documentation Errors - This is simply a failure to document a clerical, process, or technical oversight/error that results in progression of the error. All staff should be instructed and feel empowered to stop a process whenever an error is suspected. In some situations documentation failures result from the failure to report error or deviations from quality control protocols resulting in the decreased effectiveness of process measures designed to detect or correct errors. Like the errors listed above, documentation errors may result from poor training, lack of standardization, or time pressures from inadequate staff which drive people to skip steps or rush through processes.
The above errors types and possible root causes are general suggestions, and you will need to perform analysis of your own processes and error sources to determine both the root causes and effective corrective measures which uniquely apply to your laboratory's situation.