By PAMELA FAYERMAN
Forty million lab tests are done in B.C. annually. Each and every one is an opportunity for human error leading to patient harm.
In a bid to avert errors in collection, handling and analysis, a small team at the University of B.C. manufactures simulated specimens to send to labs across Canada. Technologists can maintain, or improve, their skills by practising on them.
The Clinical Microbiology Proficiency Testing (CMPT) program is led by a giant in Canadian microbiology — Dr. Michael Noble, a pathology and lab medicine professor.
He may have a low public profile, but internationally, he’s widely regarded as a pioneer and innovator in the field of microbiology quality assurance for patient safety.
The specimens that labs receive from Noble’s program are in vials containing live bacteria or other microbes, which technologists must identify correctly. The micro-organisms lurk in mediums of imitation poop, urine, blood and other bodily fluids. Stool samples, for example, are made out of mashed brown lentils, which may be “infected” with pathogens such as E. coli, C. difficile or salmonella. They look and even smell realistic, as though from a real patient.
Simulated urine or blood is made from a water-based broth coloured by certain proteins and then infected — or not — with germs the technologists must identify, if they are indeed present.
Among many others, there are simulated mediums mimicking wound specimens, vaginal smears (to check for sexually transmitted infections), and throat swabs (to check for infections such as Strep). When the fake cultures are shipped — in airtight, shatterproof Transport Canada-regulated packages — they may also contain specimens with parasites or fungal spores that those on the receiving end must try to identify.
Borrowing knowledge from the food industry, Noble discovered ways to slow the life cycle of bacteria from two to 21 days so specimens could still be fresh and viable for interpretation when they reached their far away destinations. Bacteria, for example, ferments in urine, so Noble had to figure out a way to inhibit the process with chemicals including boric acid.
Although the precise number of lab errors in this province is unknown, since there’s no legal requirement to report them to the BC Patient Safety and Quality Council or other body, Noble estimates there are several thousand each year. In a microbiology lab test study he did on voluntarily reported incidents and mistakes between 2008 and 2010, he counted 12,278 errors, including five critical mistakes that led to misdiagnosis and even one death. (Microbiology tests account for about a quarter of all lab tests; other types of tests include blood chemistry and tissue biopsies).
Said Noble, in an interview:
We’ve so far been spared from having a major problem in B.C. so we’re either lucky or very good. But the number of errors that do occur is not small and that’s taking into consideration the fact that only about 20 per cent of errors are reported.”
According to Noble, 70 per cent of errors occur before the sample is even analysed. It could be a problem of the wrong test ordered, the wrong patient, wrong tube, wrong method of collection, wrong transport (taking too long), or wrong requisition form used by the doctor.
Ten per cent of errors occur while the specimen is being tested. The technologist may, due to distraction or some other error, make a procedural mistake, shaking the tube too many or too few times, or using the wrong mixing chemicals, for example. Another 20 per cent of errors occurred after the sample had been tested, Noble said. There may be transcription errors, delay, lost reports or results sent to the wrong doctor.
Correctly analyzing the specimens, and reporting on the recommended treatment to kill the bugs, is but one challenge that Noble’s team can help address. During an interview at the UBC lab, located on the ground floor of the hospital, his employees were busy packaging specimens into bags, boxes and envelopes.
The non-profit lab provides the quality assurance service to labs on a cost-recovery basis, bringing in revenue of about $325,000 a year. Participating labs are charged ($1,500 a year) for the specimens and the evaluation, Noble said.
We’re a very good source of education and it’s a small price to pay to learn about employee competency.”
Two hundred and fifty labs across Canada receive specimens from CMPT four times a year. But Noble and his lab’s reach is global, since he has taught visiting microbiologists and lab managers from around the world how to implement similar testing processes.
His online 21-week Medical Laboratory Quality Management course instructs and certifies lab managers on quality assurance.
The testing of the UBC lab’s specimens is required as part of the B.C. College of Physicians and Surgeons-sanctioned Diagnostic Accreditation Program (DAP). Noble said there is no requirement as to the frequency:
DAP informs all labs that they must participate in proficiency testing so the labs contact us to help carry that out. I would hope that they would do it anyway, not just because they are told to do it.”
Noble, who has been nominated for a Leadership in Quality award from the BC Patient Safety and Quality Council (BCPSQC), said before the 1980s, laboratories had few methods for testing ongoing competency and proficiency of employees and lab systems.
Dr. Diane Roscoe, head of microbiology and infection control at Vancouver General Hospital, who nominated Noble for the BSPSQC award, said until Noble’s system of simulated specimens, “the only source of challenge specimens was from the College of American Pathologists.
They were purchased, freeze-dried cultures that neither looked like, nor acted like, clinical samples.”
The winner of the category in which Noble is nominated is expected to be announced at the end of this month.
Noble’s creation of the CMPT program in 1983 represented the “first pan-Canadian medical laboratory quality assessment program,” Roscoe said.
A decade later, he helped private and public labs attain international standards for accreditation, she noted.
“Dr. Noble’s involvement has not been a flash-in-the pan effort; it has been sustained now for over 30 years, and it has moved from being a small local effort to one that is national and international.”
Microbiologists and technologists from countries in Africa, Asia, the Caribbean, Europe and the Middle East have all been trained by Noble, Roscoe said.
I’ve worked with him for my entire career, and it’s remarkable how many innovations he’s responsible for.”
Earlier this week, more than 100 experts who share Noble’s passion for error avoidance were in Vancouver for the Quality Management Conference for Laboratory Medicine, a three-day meeting Noble organized.
To read more about Noble’s program, go to: http://www.medicallaboratoryquality.com
Sun Health Issues Reporter