Annals of Clinical Biochemistry > Volume 45, Number 5 > Pp. 463-466

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Original Articles

Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa

Louise Nutt, Annalise E Zemlin and Rajiv T Erasmus

Division of Chemical Pathology, National Health Laboratory Service (NHLS), Tygerberg Hospital, Stellenbosch University, Parow 7505, South Africa

Corresponding author: Dr Louise Nutt. Email: lnutt{at}sun.ac.za

Background: Research has demonstrated that most laboratory errors occur in the preanalytical phase of testing. In view of the paucity of studies examining preanalytical errors, we evaluated our laboratory request forms for the frequency and impact of incomplete data.

Methods: This study examined all request forms received at our laboratory during a five-day period. The forms were scrutinized for the presence of specific parameters. The impact of abbreviated diagnoses was analysed, as well as how lack of ward or telephone details affects the communication of critical results to clinicians.

Results: A total of 2550 request forms were analysed. Medication(s) used by the patient (89.6%) and doctor’s contact number (61.2%) were the most incomplete parameters. No diagnosis was provided on 19.1% of forms, and when a diagnosis was present it was an abbreviated form in 37.3%. This resulted in 35.5% of diagnoses not being recorded by reception staff. Incomplete ward information was found on 4.9% of forms. In a separate search, the impact of 151 request forms (collected over a period of eight months), with incomplete ward location information and corresponding to critical results was assessed. Critical results were not communicated by telephone to clinicians in 19.9% of cases.

Conclusion: As laboratory data influences 70% of medical diagnoses, incorrect or incomplete data provided to the laboratory could significantly impact the success and cost of overall treatment.

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				R T Erasmus and A E Zemlin Clinical audit in the laboratory J. Clin. Pathol., July 1, 2009; 62(7): 593 - 597. [Abstract] [Full Text] [PDF]