PLYMOUTH MEETING, PA—Laboratory testing is indispensable to patient care. Although it accounts for only 2% of U.S. healthcare expenditures, laboratory medicine is critical for accurate diagnosis and treatment planning and is the topic of ECRI Institute’s most recent safety study.

ECRI Institute PSO, one of the nation’s preeminent Patient Safety Organizations, recently conducted a Deep Dive™ analysis of laboratory-related safety events focusing on the impact of errors in the laboratory testing process on clinical decision making.

ECRI Institute PSO found that 96% of the events were associated with processes that actually occurred outside of the laboratory. Yet, organizations often said that the events they reported originated in the laboratory.

The analysis covers events which occurred from 2011 through May 2013. More than half of the 2,420 reported events were associated with three types of events: mislabeled specimens, specimens with an incomplete or missing label, and missing or delayed results.

“Strategies to reduce diagnostic errors involving laboratory testing must entail all phases of the laboratory testing process and engage all stakeholders in that process,” says Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO.

ECRI Institute PSO says the responsibility rests with everyone involved in the total testing process:

  • The provider who orders a laboratory test to aid in the care of a patient and makes decisions based on test findings
  • The individual who collects a specimen
  • The transporter who delivers the specimen to the lab
  • The lab technician who processes the test order and records the test results
  • The individual who ensures test results are available to ordering personnel

“We recommend a hierarchy of error-reduction techniques to improve the total testing process and to enhance patient safety,” adds Zimmer.

The Laboratory Testing PSO Deep Dive findings were published in a report available to all ECRI Institute PSO members and its partner PSO members. It reviews strategies for leadership support, standardizing and simplifying some processes, technology solutions, communication and teamwork, staff education, event reporting and analysis, performance improvement, and patient involvement.

The executive summary of the report is available for free viewing/download. Additional information will be presented in ECRI Institute PSO’s Monthly Brief free e-newsletter; go to to sign up. The full report with toolkit and previous Deep Dives on Health IT and Medication Safety are also available for purchase.

For questions about this topic, or for information about purchasing the report, please contact ECRI Institute PSO by telephone at (610) 825-6000, ext. 5558; by e-mail at; by fax at (610) 834-1275, or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.


About ECRI Institute
For over 45 years, ECRI Institute’s work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit Find ECRI Institute on Facebook ( and Twitter (

For more information, contact:
Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310