EventTracker: A Web-Based Tool for Reporting Adverse Events in the Clinical Laboratory

Author: Ruth A. Luna, ClSp(MB)

Primary Advisor: Gregory J. Buffone, PhD (co-author)

Committee Members:

Masters thesis, The University of Texas School of Health Information Sciences at Houston.

 
There is a critical need for documenting and monitoring adverse events and the errors that cause them in the clinical laboratory. While the scientific literature on the subject is scarce, emphasis has been placed on laboratory errors occurring during the analytical phase of testing as opposed to the pre- and post-analytical phases. While the medical community is still hesitant to report errors at all, recommendations from the Institute of Medicine have encouraged a change in culture and practice. EventTracker is a web-based application developed and adopted by the clinical laboratory at Texas Children's Hospital to aid in documenting, tracking, and reducing errors and events. The system promotes communication about errors and events among the laboratory staff, administrators, and medical directors. It is designed to allow every laboratory employee to submit an event, while managers and assistant directors are required to review, investigate, and provide feedback regarding each event.