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Background and objectives Laboratory tests are crucial for diagnosis and monitoring of thyroid disorders. It is therefore necessary to study the pattern and variability in requests of thyroid function tests. The study objectives were to compare the inter-regional variability in the request of laboratory thyroid tests by general practitioners (GPs) in Spain, and to investigate the potential economic savings if the goals set for some suitability indicators were reached. Methods Test requests per 1000 inhabitants and test ratios (free thyroxine (FT4)/thyrotropin (TSH), free triiodothyronine (FT3)/TSH, thyroglobulin antibody (TgAb)/peroxidase antibody (TPOAb)) were compared between the different areas, according to their setting, location, and management. The resulting savings if each department achieved the goals for indicator (0.25 for FT4/TSH, 0.1 for FT3/TSH) were estimated. Results Seventy-six laboratories covering a population of 17,679,195 inhabitants participated in the study. TSH was requested significantly less in urban-rural areas, and the requests for FT3/1000 inhabitants, FT3/TSH, and TgAb/TPOAb were higher in departments with private management. The savings generated if specifications for the ratios of related tests were met would be 937,260.5 €. Conclusions The high variability reported in requests for thyroid function and autoimmunity tests in Spain suggests the need for implementing strategies to improve use of such tests.

Purpose – The authors present the application of the López-Fresno approach in designing an integrated management system (IMS) for an aviation company to the development of an IMS in a government-run organization responsible for the medical evaluation of work disabilities. The purpose of this paper is to share the design process, with the intention of showing that this approach is applicable to other sectors and proposing generalization and applicability strategies to other smaller government entities. Design/methodology/approach – The study involves two phases. Phase I applies the López-Fresno approach to design a basic IMS-I and ends with a European Foundation for Quality Management (EFQM) evaluation, whose suggestions were taken into consideration for the final design of IMS-II during phase II. The data were obtained from the organization's own functioning. There was a significant degree of personal involvement by the authors, external consultants and members of the management committee in areas ranging from the approach itself to the various components analyzed. Findings – The approach led to a better use of human and material resources and produced various advances in both internal and external communication and significant progress in employee motivation in their dealings with users and stakeholders. Originality/value – The study offers guidelines and recommendations for designing an IMS adapted to small, compact, administrative organizations that operate with stakeholders with highly disparate outlooks and interests, with different quality levels, in a context related to competitiveness and economic development.

Background It is necessary to achieve a reduction in the number of requests for laboratory tests by improving the appropriateness of testing behaviour. The aim of the study was, first, to compare laboratory requiring patterns for emergency department (ED) patients in clinical laboratories of different institutions in Spain; second, to design an appropriateness pre-pre-analytical quality control report based on appropriateness indicators. Methods A call for data was posted on a website. We obtained production statistics for the year 2010 from emergency laboratories at 36 hospitals. Two types of appropriateness indicators were calculated: test request per 1000 ED admissions or related test requesting ratios. In order to explore the inter-practice variability in tests requests, the ‘index of variability’ was calculated. A pre-pre-analytical quality control report was designed, prepared and sent to each participating laboratory. The savings generated, if each Health-care Department would have achieved the appropriate indicator standard, were calculated. Results The rate of request of the stat tests ranged from 44 to 412 per 1000 ED patient admissions. There was a high and peculiar dispersion of related test requesting ratio results. If every single laboratory would have achieved the appropriate indicator, we would have saved 1,019,230 urea, 302,511 AST and 316,161 CK unnecessary tests. Conclusions There are large variations of test requesting in the emergency setting. An appropriateness pre-pre-analytical quality control report was useful for comparing requesting patterns. The study shows the need to unify demand. The key to achieve this goal will be interdepartmental cooperation between ED clinicians and laboratory professionals.

La cultura sobre seguridad se perfila como uno de los requisitos para evitar la aparición de efectos adversos, sin embargo no se ha estudiado en el ámbito de la cardiología. El objetivo es evaluar la cultura de seguridad en una unidad de cardiología que tiene implantado y certificado un sistema integrado de gestión de calidad y riesgos para la seguridad del paciente. Método: Se realizó un estudio observacional trasversal en 2 años consecutivos utilizando la encuesta Hospital Survey on Patient Safety Culture de la «Agency for Healthcare Research and Quality» en su versión española (42 ítems agrupados en 12 dimensiones) sobre todo el personal. Se comparó el porcentaje de respuestas positivas de cada dimensión en 2014 y 2015, así como con los datos a nivel nacional y en EE. UU., siguiendo las recomendaciones establecidas. Resultados: La valoración global, sobre un máximo de 5, fue de 4.5 en 2014 y de 4.7 en 2015. Identificamos 7 dimensiones como fortaleza. Las peor valoradas fueron: Dotación de personal, Apoyo de la gerencia y Trabajo en equipo entre unidades. La comparación mostró superioridad en todas las dimensiones a nivel nacional, y en 8 respecto a los datos del registro americano. Conclusiones: La cultura de seguridad en una unidad de cardiología con un sistema integrado de gestión de calidad y riesgos y seguridad del paciente es elevada, superior a la nacional en todas sus dimensiones y en la mayoría de ellas respecto al registro de EE. UU. The safety culture is one of the requirements to prevent the occurrence of adverse effects, however has not been studied in the field of cardiology. The objective is to evaluate the safety culture in a cardiology unit has implemented and certified an integrated quality and risk management for patient safety system. Methods: A transversal observational study was made in 2 consecutive years using the survey “Hospital Survey on Patient Safety Culture” of the “Agency for Healthcare Research and Quality” in its Spanish version (42 items grouped into 12 dimensions) in all staff. The percentage of positive responses in each dimension in 2014 and 2015 were compared, as well as national data and United States data, following the established rules. Results: The overall assessment of a possible 5, was 4.5 in 2014 and 4.7 in 2015. We identified seven dimensions as a fortress. The worst rated were: staffing, management support and teamwork between units. The comparison showed superiority in all dimensions respect to national data, and 8 respect to American data. Conclusions: The safety culture in a Cardiology Unit with an integrated quality and risk management and patient safety system is high, higher than the national in all its dimensions and in most of them respect to the United States.

Safety culture is one of the requirements for preventing the occurrence of adverse effects. However, this has not been studied in the field of cardiology. The aim of this study is to evaluate the safety culture in a cardiology unit that has implemented and certified an integrated quality and risk management system for patient safety.A cross-sectional observational study was conducted in 2 consecutive years, with all staff completing the Spanish version of the questionnaire, "Hospital Survey on Patient Safety Culture" of the "Agency for Healthcare Research and Quality", with 42 items grouped into 12 dimensions. The percentage of positive responses in each dimension in 2014 and 2015 were compared, as well as national data and United States data, following the established rules.The overall assessment out of a possible 5, was 4.5 in 2014 and 4.7 in 2015. Seven dimensions were identified as strengths. The worst rated were: staffing, management support and teamwork between units. The comparison showed superiority in all dimensions compared to national data, and in 8 of them compared to American data.The safety culture in a Cardiology Unit with an integrated quality and risk management patient safety system is high, and higher than nationally in all its dimensions and in most of them compared to the United States.

Objective. To analyze the requesting patterns for a range of laboratory tests ordered in 2009 from eight laboratories providing services to eight health areas, using appropriate indicators. Design. Indicators measured every test request per 1,000 inhabitants, and indicators that measured the number of tests per related test requested by general practitioners were calculated. The savings generated, if each Health Care Department achieved the appropriate indicator standard, were also calculated. Laboratory Information System registers were collected, and indicators were calculated automatically in each laboratory using a data warehouse application. Results. There was a large difference in demand for tests by health areas. The ratio of related tests also showed a great variability. The savings generated if each Health Care Department had achieved the appropriate indicator standard were €172,116 for free thyroxine, €18,289 for aspartate aminotransferase, and €62,678 for urea. Conclusions. Considerabl...

Resumen Introduccion El objetivo del trabajo es mostrar y analizar los resultados de errores preanaliticos en las muestras de laboratorio remitidas desde atencion primaria a 7 laboratorios de la Comunidad Valenciana que atienden a 7 departamentos de salud. Material y metodos Se realizo un estudio transversal mediante la evaluacion y el analisis de los errores preanaliticos de 7 laboratorios. El error preanalitico se definio como muestra que no puede ser analizada por no cumplir los criterios de aceptabilidad o que no se recibe en el laboratorio. Se disenaron indicadores de proporcion que cuantifican cada incidencia respecto al total de cada muestra (hematologia, coagulacion, bioquimica y orina). Los errores preanaliticos y las muestras se recogieron automaticamente del Sistema de Informacion del Laboratorio, y tambien se calcularon los indicadores a tiempo real mediante un software basado en data warehouse y cubos OLAP. Resultados La variabilidad de los resultados entre los diferentes centros fue elevada, evidenciandose que el mayor porcentaje de incidencias se debio a la falta de disponibilidad de las muestras, en especial de coagulacion y de orina. Conclusiones Existe una gran variabilidad de errores preanaliticos dependiendo del Departamento de Salud. Existe una necesidad de homogeneizar la practica de la extraccion de muestras.

Resumen Objetivo Mostrar el patron de solicitud de hemoglobina glucosilada (HbA 1c ) en ocho departamentos de salud mediante el calculo de indicadores de adecuacion de la demanda. Metodos Estudio transversal en el que se recogen el numero de HbA 1c solicitadas desde Atencion Primaria durante los anos 2008 y 2009. Como indicador de adecuacion se calculo el porcentaje de valores de HbA 1c con resultado inferior a 6,5%. Las variables y los indicadores se recogieron y calcularon de forma automatizada. Tambien se calculo en cada departamento de salud el numero de determinaciones de HbA 1c teoricas que deberian haber sido solicitadas segun datos de prevalencia conocida. Resultados se observo un incremento progresivo de la demanda de determinaciones de HbA 1c y, aproximadamente el 54% de los valores de HbA 1c en siete de estos ocho departamentos fueron inferiores a 6,5%. El numero de HbA 1c teoricas que deberian haber sido solicitadas segun la prevalencia de diabetes fue mayor que el numero solicitado en todos los departamentos. Conclusion Los resultados parecen indicar la inadecuacion en la solicitud de la HbA 1c en los departamentos de salud estudiados, no solo por la probable sobreutilizacion en pacientes no diabeticos sino por la infrautilizacion en pacientes que si lo son.

Purpose To show turnaround time to client source in eight laboratories covering eight Health Areas (2,014,475 inhabitants) of the Valencian Community (Spain). Material and methods Internal Laboratory Information System (LIS) registers (test register and verification date and time), and daily LIS registers were used to design the indicators, These indicators showed the percentage of key tests requested (full blood count and serum glucose and thyrotropin) that were validated on the same day the blood was taken (inpatients and Primary Care and/or at 12 a.m. (inpatients). Urgent (stat) tests were also registered as key tests (serum troponin and potassium) and were recorded in minutes. Registers were collected and indicators calculated automatically through a Data Warehouse application and OLAP cube software. Results Long turnaround time differences were observed at 12 a.m. in inpatients, and in the day of sample extraction in primary care patients. The variability in turnaround of stat tests is related to hospital size, activity and validation by the laboratory physician. Conclusions The study results show the large turnaround time disparity in eight Health Care Areas of Valencian Community. The various requesting sources covered by the laboratories create the need for continuous mapping processes redesign and benchmarking studies to achieve customer satisfaction.

Objective: The aim of this study was to show how opportunities for improving laboratory performance can be identified by monitoring indicators. The testing process was also monitored using indicators to evaluate the impact of improvement measures on laboratory service and customer satisfaction. Methods: The process, which began with the delivery of samples to the laboratory and ended with a laboratory report, was evaluated over an 80-month study. The laboratory process was monitored before and after improvement measures were introduced using a series of indicators as transport, timely verified blood glucose requests, workload, and customer satisfaction indicators. Three improvement measures were implemented: redesign of the courier route, incorporation of automated sample distribution technology, and hiring another courier. Results: All of the improvement measures implemented led to a favorable evolution of the evaluated indicator. Conclusions: The use of simple strategies improved the efficacy of this laboratory’s testing process and customer satisfaction. * PCCs : primary care centers TAT : turnaround time LIS : laboratory information system OLAP : online analytical processing ANOVA : variance analysis

Objetivo Mostrar el numero y tipo de incidencias preanaliticas en los centros de extraccion periferica (CEP) del Departamento de Salud 17 de la Agencia Valenciana de Salud. Metodo El estudio se ha llevado a cabo durante 35 meses (mayo 2005�marzo 2008) sobre las 362.054 solicitudes y las 2.880.742 pruebas que se han recibido de los 16 CEP de Atencion Primaria del Departamento de Salud 17. Metodo Las incidencias son registradas en el sistema de informacion de laboratorio mediante un resultado codificado especifico en la prueba solicitada. La procedencia de la muestra afectada se conoce mediante el numero de peticion que es especifico para cada CEP. Metodo Los resultados codificados y las muestras afectadas son recogidos automaticamente mediante un software basado en cubos On-Line Analytical Processing (OLAP) (Omnium®, Roche Diagnostics®). Calculamos las incidencias (expresadas en defectos por millon de oportunidades) para cada tipo de muestra en cada uno de los CEP. Se clasificaron los errores preanaliticos en dos grandes grupos: errores debidos a la pericia extractora (muestra coagulada, insuficiente o hemolizada) y error debido a fallo de proceso (muestra no disponible). El tratamiento de los datos obtenidos se ha realizado mediante Microsoft Excel 2003. Las variables son expresadas como frecuencia y porcentaje. Resultados El mayor numero de incidencias tuvo lugar en las muestras de orina (5.358 [52%]), seguidas por las de coagulacion (2.164 [21%]), hematologia (1.752 [17%]) y bioquimica (1.030 [10%]). Con respecto al tipo de error, la mayor proporcion de errores fue debida a fallos de proceso (7.007 [62%]). Conclusiones La alta incidencia de errores preanaliticos y su variabilidad entre centros sugieren que existe una necesidad de homogeneizar la practica de la extraccion de muestras.

Background: Accreditation agencies now require clinical laboratories to list critical limits, formulate notification procedures, document critical results, and notify clinicians. The objective of this study has been to perform a retrospective review of our critical value notification procedure and improve it by reaching a consensus with our clinicians. Methods: The main outcome measures were the number of critical values (CVs) reported in our laboratory and the number and rate of CVs if we had applied the universal critical limit list used by the majority and the supercritical limit list. Results: Fifty-four CVs were reported with 660 theoretical CVs and 120 supercritical CVs. The list CV and notification procedure was improved according to expert opinion. Conclusion: Every laboratory should have at its disposal a procedure to notify critical results. A consensus should be reached with clinicians to establish a specific list of critical limits according to the type of patient and the timeliness of laboratory tests.

Introduction: The study was performed to compare and analyze the inter-departmental variability in the request of rarely requested laboratory tests in primary care, as opposed to other more common and highly requested tests. Materials and methods: Data from production statistics for the year 2012 from 76 Spanish laboratories was used. The number of antinuclear antibodies, antistreptolysin O, creatinine, cyclic citrullinated peptide antibodies, deaminated peptide gliadine IgA antibodies, glucose, protein electrophoresis, rheumatoid factor, transglutaminase IgA antibodies, urinalysis and uric acid tests requested was collected. The number of test requests per 1000 inhabitants was calculated. In order to explore the variability the coefficient of quartile dispersion was calculated. Results: The smallest variation was seen for creatinine, glucose, uric acid and urinalysis; the most requested tests. The tests that were least requested showed the greatest variability. Conclusion: Our study shows through a very simplified approach, in a population close to twenty million inhabitants, how in primary care, the variability in the request of laboratory tests is inversely proportional to the request rate.

Background: To compare the inter-practice and inter-regional variability in laboratory test requests by general practitioners in Spain, through the measure of appropriateness indicators. Methods: A call for data was posted on the Redconlab website. We obtained production statistics for 2010 from laboratories in 37 different hospitals from diverse Spanish regions. The following appropriateness indicators were calculated: test re-quests per 1000 inhabitants, ratios of related tests requests and index of variability. The results obtained in the laboratories in the region of authors were com-pared to the rest of the participating laboratories in order to establish whether there were regional differences in the test requesting patterns. Results: The rate of request of the tests ranged from 31.5 per 1000 inhabitants for vitamin B12 to 372.6 per 1000 inhabitants for glucose. The index of variability ranged from 1.53 for glucose and triglycerides to 7.4 for alkaline phosphatase. Regarding the ratios of related test requests, the variability index ranged from 1.24 for folic acid/vitamin B12 to 26.38 for lactate dehydrogenase/alanine transaminase. The most frequently ordered tests were the ones with less variability, except for uric acid and urinalysis. No significant differences were identified between the results of the laboratories in the region of authors and the rest, except for urinalysis (p < 0.001), folic acid/vitamin B12 (p = 0.030), and transferrin/ferritin (p = 0.018). Conclusions: A considerable variability exists in laboratory test ordering patterns by general practitioners across Spanish regions. Local habits must have been decisive as shown by the regional differences in the results of indicators of some tests. The study results bring out the need to accomplish interventions to improve appropriate use of laboratory tests.

SUMMARY Background: A correct preanalytical phase procedure is critical to get an adequate sample and consequently to achieve the most reliable laboratory results, promoting patient safety. Continuous laboratory staff changes create the need to establish improvement strategies to reduce the error risk. The objective was to show how the numbers of preanalytical errors related to unsuitable samples in a hospital setting decrease following two improvement strategies related to new technology and educational actions and how their effects were measured by monitoring indicators. Methods: Samples were drawn by the laboratory and other hospital departments’ nurses without previous patient appointment, therefore, prior tube preparation was not available before the phlebotomy. Corrective measures for these activities were established: educational program for nurses and a system of custom labels, which correlate each laboratory test in the Laboratory Information System (LIS) with the corresponding tube. Three phases were defined based on the implementation dates of the improvement actions to be assessed. The set of indicators designed to monitor the improvement related to clotted, hemolyzed, insufficient, and uncollected samples. Data were collected and indicators calculated from the LIS using a data warehouse application. Patient satisfaction with respect to phlebotomy was also measured annually using a scoring survey. Results: There was a reduction in all types of preanalytical sample errors related to the improvement strategies adopted. The indicators demonstrated that the unavailable, insufficient, and clotted samples decreased between two- and three-fold, whereas hemolysis errors benefited more from these improvement strategies. Patient satisfaction with the laboratory and phlebotomy procedures improved over the past several years as based on the annual satisfaction surveys. Conclusions: The educational program for nursing personnel is relevant and important as can be seen in the decrease of sample errors and the resulting quality improvement. The custom label system minimizes the potential oversight of forgetting to draw a tube, which happens frequently when operating without appointments, by printing the labels according to requested tests. Detection, identification, and monitoring of the error and implementing strategies to improve preanalytical quality reduces error numbers and thereby improves patient safety and health system outcomes. (Clin. Lab. 2012;58:911-917. DOI: 10.7754/Clin.Lab.2012.111111)

Background: To evaluate the hemoglobin A1c (HbA1c) prescription patterns by primary care physicians before the International Expert Committee (IEC) guidelines and how they have changed. Materials and Methods: The number of HbA1c tests ordered from January 2002 to December 2009 was examined in a cross-sectional study. The percentage of HbA1c results

The purpose of this quasi-experimental study was to assess levels of compliance with the intervention bundles contained in a clinical pathway used in the treatment of patients with severe sepsis and septic shock, and to analyze the pathway’s impact on survival and duration of hospital stays. We used data on 125 patients in an Intensive Care Unit, divided into a control group (N=84) and an intervention group (N=41). Levels of compliance increased from 13.1% to 29.3% in 5 resuscitation bundle interventions and from 14.3% to 22% in 3 monitoring bundle interventions. In-hospital mortality at 28 days decreased by 11.2% and the duration of hospital stay was reduced by 5 days. Although compliance was low, the intervention enhanced adherence to the instructions given in the clinical pathway and we observed a decline in mortality at 28 days and shorter hospital stays. El objetivo de este estudio cuasiexperimental fue valorar el nivel de cumplimiento de las intervenciones de los paquetes de medidas de un protocolo clínico para pacientes con sepsis grave y shock séptico y analizar su impacto sobre la supervivencia y la duración de estancias hospitalarias. Se incluyeron los datos de 125 pacientes divididos en grupo control (N=84) e intervención (N=41) de una Unidad de Cuidados Intensivos. El nivel de cumplimiento aumentó de 13,1% a 29,3% en 5 intervenciones del paquete de reanimación y de 14,3% a 22% en 3 intervenciones del paquete de seguimiento. La mortalidad hospitalaria a los 28 días disminuyó un 11,2% y la duración de la estancia hospitalaria se redujo en 5 días. Aunque el cumplimiento fue bajo, la intervención aumentó la adhesión a las indicaciones del protocolo clínico y se observó un descenso de la mortalidad a los 28 días y menor duración de estancias hospitalarias.

The aim of the study is to compare the use of PSA testing among general practitioners (GPs).The number of PSA tests ordered by general practitioners in the years 2008-2009 was examined in a cross-sectional study of nine health districts of Spain. The percentage of PSA ordered to men younger than 50 (PSA50/PSAtotal) and 40 years (PSA40/PSAtotal) was calculated. The percentage of men over 50 years who were attended was also calculated and this data was compared with the number of PSA ordered to this population. For two of the departments, these data were also compared between GPs and urologists.PSA testing in 2009 is higher than 2008 in seven health districts. PSA testing in men younger than 50 years was increased along the period of the study and in men younger than 40 years remained steady. The differences between the values of the indicators for urologists and GPs are significant.The number of PSA tests and the percentage performed to men younger 50 years has been increasing and the variability is high. These data are suggestive for interventions focused on PSA testing and prostate cancer screening in primary care settings.

Objective To assess the pattern of glycosylated hemoglobin (HbA1c) requests by clinicians from eight health care departments by calculating indicators of demand appropriateness. Methods A cross-sectional study of the number of HbA1c requests by primary care clinics in 2008 and 2009. The indicator of demand appropriateness was the proportion of HbA1c values lower than 6.5%. Variables were collected and indicators were automatically calculated. The number of HbA1c measurements that should theoretically have been requested according to known diabetes prevalence data was also calculated. Results A progressive increase was seen in the demand for HbA1c measurements. Approximately 54% of HbA1c values obtained in seven of the eight departments studied were lower than 6.5%. The number of theoretical HbA1c requests that would have been expected based on the known prevalence of diabetes was higher than the number of HbA1c requests in all departments. Conclusion The results appear to suggest that HbA1c requests in the health care departments studied were not always appropriate. HbA1c measurements were probably overused in patients without diabetes and underused in patients with diabetes.

The objectives of this research were to show the most frequent preanalytical sample errors from two distinct patient populations and blood-drawing personnel, to calculate preanalytical quality specifications, and to demonstrate an improvement strategy for patients whose samples have been drawn in the primary health care center by means of a monthly preanalytical quality control report based on statistical process control (SPC).We collected preanalytical errors from the tests requested for hematology, coagulation, chemistry, and urine samples in both populations. To monitor an improvement strategy, we designed a set of indicators. The indicator results for 35 months were entered into the statistical software application, where they were statistically analyzed. The preanalytical quality specifications were calculated using the SPC control charts. The intervention consisted of the sending of a monthly preanalytical quality report to a pilot Decentralized Phlebotomy Center (DPC) and setting up a direct communication channel between the laboratory and the DPC.Fewer errors were observed when the sample drawing was carried out by the laboratory personnel, showing distinct preanalytical quality specifications. Improvements were seen in the DPC after four months of the improvement strategy.We show a practical and effective methodology for the identification, monitoring, and reduction of preanalytical errors using the technology employed in daily total testing laboratory process.

Background: Laboratory performance can be measured using a set of model key performance indicators (KPIs). The design and implementation of KPIs are important issues. KPI results from 7 years are reported and their implementation, monitoring, objectives, interventions, result reporting and delivery are analyzed. Methods: The KPIs of the entire laboratory process were obtained using Laboratory Information System (LIS) registers. These were collected automatically using a data warehouse application, spreadsheets and external quality program reports. Customer satisfaction was assessed using surveys. Nine model laboratory KPIs were proposed and measured. Results: The results of some examples of KPIs used in our laboratory are reported. Their corrective measurements or the implementation of objectives led to improvement in the associated KPIs results. Conclusions: Measurement of laboratory performance using KPIs and a data warehouse application that continuously collects registers and calculates KPIs confirmed the reliability of indicators, indicator acceptability and usability for users, and continuous process improvement. Clin Chem Lab Med 2010;48:57–61.

The aim of the study is to show the most frequent preanalytical sample errors from distinct decentralized phlebotomy centers.The study was conducted from May 2005 to March 2008. In this period 36,2054 requests and 2,880,742 tests were received from the 16 decentralized phlebotomy centers. When an unsuitable sample is received specific coded results are registered as test results to inform the physician that an error had occurred and a new specimen collection is recommended. We used the the request number, which is specific for each phlebotomy center to ascertain where the samples with errors had been drawn, The preanalytical errors were identified by looking for coded results and were collected automatically from the LIS using a software program based on OLAP's cube (Omnium Roche Diagnostic), obtaining number and type of preanalytical error for each sample. The errors are calculated as number per million samples requested. Analysis of data was carried out using Microsoft Excel 2003. Categorical variables were expressed as frequency and percentage.The highest number of incidences occurred in urine samples (52%), followed by coagulation (21%), haematology (17%) and biochemistry (10%). With regard to the type of error, the largest proportion of errors was due to failures of process (62%).The high incidence of preanalytical errors and variability between centers suggests that there is a need to standardize the drawing practice.

ResumenObjetivoproponer un sistema de indicadores como instrumento de dirección para el laboratorio clínico, desde la perspectiva de gestión interna de un cuadro de mando integral.Material y métodoslos indicadores se obtienen de distintas fuentes, a través de registros internos del sistema informático del laboratorio, control externo de calidad de la Generalitat Valenciana. Se muestran los resultados de los indicadores de proceso analítico (proporción) de un año.Resultadosse proponen indicadores de gestión interna (divididos en proceso, adecuación y control de calidad). Los indicadores de proceso muestran una progresiva mejora desde su establecimiento.Conclusióntras un año de utilización de los indicadores de proceso analítico de un cuadro de mando integral en el laboratorio, los resultados obtenidos validan su utilidad como instrumento para la gestión del laboratorio.AbstractObjectiveto propose a set of indicators as a management tool for a clinical laboratory, by using the balanced scorecard internal business processes perspective.Material and methodsindicators proposed are obtained from different sources; external proficiency testing of the Valencia Community Government, by means of internal surveys and laboratory information system registers. One year testing process proportion indicators results are showed.Resultsinternal management indicators are proposed (process, appropriateness and proficiency testing). The process indicators results show gradual improvement since its establishment.Conclusionafter one years of using a conceptually solid Balanced Scorecard Internal business processes perspective indicators, the obtained results validate the usefulness as a laboratory management tool.

to propose a set of indicators as a management tool for a clinical laboratory, by using the balanced scorecard internal business processes perspective.indicators proposed are obtained from different sources; external proficiency testing of the Valencia Community Government, by means of internal surveys and laboratory information system registers. One year testing process proportion indicators results are showed.internal management indicators are proposed (process, appropriateness and proficiency testing). The process indicators results show gradual improvement since its establishment.after one years of using a conceptually solid Balanced Scorecard Internal business processes perspective indicators, the obtained results validate the usefulness as a laboratory management tool.

Background: Knowledge about the variability in the request of calcium-phosphate metabolism laboratory tests in primary care is important to design strategies to improve health system efficiency. Aim: To compare the inter-practice variability in calcium-phosphate metabolism laboratory tests requested by general practitioners from diverse regions across Spain. Material and Methods: One hundred and forty one clinical laboratories were invited to participate in an observational cross-sectional study. They informed the number of serum calcium, phosphate, parathyroid hormone and 25-hydroxyvitamin D requested by general practitioners. Appropriateness indicators were calculated as number of test requests per 1,000 inhabitants and ratio of related tests requests. The differences according to hospital setting, region and type of management were analyzed. Results: We recruited 76 laboratories (17,679,195 inhabitants). General practitioners requested 3,260,894 calcium-phosphate metabolism tests. The rate of request ranged from 2.97 per 1,000 inhabitants for 25-hydroxyvitamin D to 98.89 per 1,000 inhabitants for calcium. The rates of request for calcium, phosphate, parathyroid hormone in some areas were 30, 100 and 340 times higher than in other areas. Parathyroid hormone and 25-hydroxyvitamin D were highly requested in private management areas. There were also differences in phosphate, parathyroid hormone and 25-hydroxyvitamin D requesting between regions across Spain. Conclusions: The high variability observed is difficult to explain by differences in patient case mix between regions. Depending on the area, calcium could be under requested to detect primary hyperparathyroidism. Objetivo: Conocer la variabilidad en la solicitud de pruebas de laboratorio en atención primaria es importante para diseñar estrategias que mejoren la eficiencia del sistema de salud. La propuesta de este estudio fue comparar la variabilidad en la solicitud de pruebas para la evaluación del metabolismo fosfocálcico por médicos de atención primaria de diversas regiones de España. Material y Método: Se invitó a participar a 141 laboratorios clínicos de diversas regiones españolas. Completaron una encuesta con el número de determinaciones de calcio, fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitadas por médicos de atención primaria de sus áreas. Se calcularon las tasas en relación a la población y se construyeron indicadores de adecuación. Los resultados se compararon por características del hospital, región y tipo de gestión. Resultados: Obtuvimos los datos de 76 laboratorios (17.679.195 habitantes). Los médicos de atención primaria solicitaron 3.260.894 pruebas de metabolismo fosfocálcico. La tasa de solicitud varió de 2,97 por 1.000 habitantes de 25-hidroxivitamin D a 98,89 por 1.000 habitantes de calcio. Las tasas de calcio, fósforo, hormona paratiroidea en algunas áreas fue 30, 100 y 340 veces más alta respecto a otras. Hormona paratiroidea y 25-hidroxivitamina D fueron más solicitadas significativamente en hospitales con gestión privada. También hubo diferencias en fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitas entre distintas regiones de España. Discusión: La alta variabilidad observada es difícil de explicar por las diferencias de las características de los pacientes. Dependiendo de la región podría haber una infra solicitud para la detección del hiperparatiroidismo primario.