Learning from the errors of others: An exploration of error in the total analytical process 

3.0 ACCENT credits / 3.0 CME credits
Sunday, July 27, 2025
Afternoon course | 1:30 – 4:30 p.m. US Central Time
McCormick Place Chicago

Description

Laboratory professionals are frequently confronted with investigating the validity of the results generated in the laboratory, for which a myriad of possible explanations must be considered. Troubleshooting expertise is most frequently gained on the job, which puts some individuals at a disadvantage if they are new to the field, or are newly promoted to a leadership position with responsibility for detecting and correcting error conditions. The purpose of this course is to provide attendees with an opportunity to learn about common and uncommon errors in all three phases of laboratory testing (pre-analytical, analytical, and post-analytical). The faculty for this course has over 45 years of combined experience in clinical chemistry and laboratory testing, and will use a combination of expert lecture, interactive (audience response) case studies, and small group discussions to highlight challenging error events as well as methods to detect and mitigate the risk of future errors.

Target audience

This activity is designed for lab supervisors, lab directors (and/or assistant directors), lab managers (supervisory and/or non-supervisory), medical technologists, point-of-care coordinators, pathologists, and in-training individuals.

Presentation level

Basic

Prerequisite knowledge 

General knowledge in the following is recommended:

• Nature of the additives in evacuated blood collection tubes
• Physiologically possible/probable results of routine laboratory tests
• Familiarity with analyte concentrations associated with laboratory diagnosis of disease (e.g., diabetes mellitus)

What to bring

A laptop or personal device for notetaking and audience participation.

Learning objectives

After participating in this course, participants will be able to:

• Describe three common pre-analytical, analytical, and post-analytical errors that impact patient results.
• Determine if these errors impact patient results in their own laboratories.
• Develop methods and strategies to prevent and/or mitigate these errors in their own laboratories.

Skills you will gain

• Interpret results that may be impacted by common laboratory errors.
• Recognize and address common causes of laboratory errors.

Faculty

Mark Cervinski, PhD, DABCC, FADLM | Dartmouth Health

Aaron Geno, PhD, DABCC | Dartmouth Health

Alison Woodworth, PhD, DABCC, FADLM | CTI Clinical Trials & Consulting

Course outline

1. (5 min) Welcome and introductions (Mark Cervinski)
   
   
2. (35 min) Preanalytical errors: Case-based examples and troubleshooting tools (Alison Woodworth) 
   Dr. Woodworth will present cases of preanalytical errors common in the lab. The cases will illustrate the effects of patient physiology and disease states, specimen collection, transport, processing and storage, and similar sounding tests. Audience response and polling will be used throughout.
   
   
3. (15 min) Breakout: Tube additives and order of draw (Alison Woodworth) 
   Participants will be divided into groups for a hands-on interactive competition in which the each team will sort evacuated blood collection tubes (vacutainers) in the following rounds:
   • Round 1: Tube sorting according to sample type: serum, plasma, or whole blood
   • Round 2: Tube placement into correct order of draw
   • Round 3: Microtainer tube placement into correct order of draw
   In addition to the lessons learned from the exercise, Dr. Woodworth will use two cases of preanalytical error – improper tube selection and order of draw –illustrate their importance and share practical strategies to mitigate.
   
   
4. (35 min) Analytic errors: The usual suspects, common analytical scenarios and IT tools to detect error (Mark Cervinski) 
   Dr. Cervinski will discuss cases of analytical errors encountered in the lab and tools for detecting errors. Methods presented include traditional quality control, LIS rules such as improbability, delta checks, and patient-based quality control, and assay cross-reactivity. Audience polling will be used throughout.
   
   
5. (15 min) Breakout: Spot the source of error (Mark Cervinski) 
   Attendees will be broken into three groups. Each group will be given a case to review, determine the likely source of error, and then present findings to larger group. Faculty facilitators will guide the group discussions.
   
   (15 min) Break
   
   
6. (35 min) Post-analytical errors: I don’t think that result means what you think it means (Aaron Geno)
   Dr. Geno will present cases of post-analytical errors and discuss how they were identified, and how they were resolved. Errors covered include unit conversion confusion, analytically accurate but clinically inaccurate values, and the failure to understand homeostasis – the trap of inappropriately “normal” results.
   
   
7. (20 min) Panel Q&A (All) 
   
   
8. (5 min) Closing (Mark Cervinski)