Issue 16  May 13th 2016

Stories from the front line of the lab: The impact of my lab error

Quote: “Every Med Tech has made errors in his or her lifetime. We are all human and good people make errors.”

When it comes to working with patients, whether that is in front or behind the bench, we have a heightened sense of our limitations in the workplace as we want to do no harm to those we care for. However, as much as we try to prevent mistakes, sometimes it happens unintentionally. This article describes a near miss error that could have been fatal for a 3 month old child. Was it the Tech’s fault? Are there other factors that contributed, such as being a junior employee, night shift work hours, lack of supervision and/or demanding physician?

Thankfully, the story has a happy ending. There are lessons that can be learned from hearing about another’s experience that you will want to read about. In fact, you may know the situation all too well! In addition to reminders of safety and quality control, there are workload and process considerations that can be extrapolated, and a reminder to staff and management that we need to strive to limit the possibility of such errors where we can.

MIT Developed a Paper-Based Test That Can Detect the Zika Virus

At this time, there are two common Zika testing methods that are being used:

1) examination for specific traces of antibodies against the virus in the blood stream, and

2) investigation for viral genome particle remnants in the blood stream (polymerase chain reaction test).

Given that the testing may take days to complete and the rapid co-circulating of multiple viruses in the same geographical locations, the current testing limitations need to be overcome to support at risk populations.

Researchers in North America, including MIT, have created a paper-based test to diagnose the Zika virus and distinguish it from other infections within a few hours. As a tool for the field, it can be stored at room temperature and be read with a simple electronic reader. The results have been published in the journal Cell.

The test is built off of technology developed for Ebola detection, which used a synthetic gene network embedded into paper (colour changes when activation occurs). “What’s really exciting here is you can leverage all this expertise that synthetic biologists are gaining in constructing genetic networks and use it in a real-world application that is important and can potentially transform how we do diagnostics,” states Julius Lucks, an assistant professor of chemical and biomolecular engineering at Cornell University.

Related Article: New Evidence Finds that Zika Virus Could Cause a Severe Neurological Disorder

What everyone should know about lab tests

Newly published research from the United States shows that medical errors cause a staggering 251,000 deaths per year and is the third leading cause of death after heart disease and cancer. If we define medical error as "an act of omission or commission in planning or execution that contributes or could contribute to an unintended result," it infers the inclusion of failures in lab testing as well.

• It is estimated that diagnostic errors occur approximately 2 million times per year in U.S. outpatients (1 in 20 adults).

• The Institute of Medicine concluded that most people will experience at least one diagnostic error in their life.

The article author suggests that there is a general misconception that laboratory tests are somehow always accurate. She writes, “Everyone should know that whether due to misuse or a failure mode, all lab tests have limitations. Some of the most common reasons include mistakes in ordering lab tests—meaning the right tests are not ordered at the right time—and problems with the accuracy, availability, and interpretation of their results. Dive into this article to find some “things to keep in mind” to help overcome some lab test-related errors.

Related Article: Medical error—the third leading cause of death in the US