Cancelled lab tests—study analyzes why

It’s possible that utilization concerns rather than preanalytical problems were driving the high cancellation rates at some institutions in this study, Dr. Darcy says. But that doesn’t mean the rate of test cancellation is somehow not a quality indicator, she cautions. “Let’s say it’s all related to much stricter utilization. Even so, there’s the opportunity to go back and find out why people are ordering inappropriately. It’s a problem, I think, no matter what the reason is.”

The study found two statistically significant associations: Lower test cancellation rates occurred in larger institutions and in laboratories that received fewer blood specimens from inpatients.

It’s not quite clear why larger institutions had lower test cancellations, Dr. Darcy says. “Large institutions seemingly would have more different people collecting, but we didn’t collect this data. Could it be that larger institutions have more lab-collected specimens, or is it that they have more rigorous training programs for collectors? We’d have to dig deeper to find out.”
The study authors were less surprised by the finding that outpatient specimens tend to lead to few test cancellations. This may be due to the complexity of orders for inpatients, the difficulty of collecting a quality specimen from inpatients, or the competency of the collector.

Says Dr. Perrotta: “When you deal with more inpatients, a lot of the time you’ll have more nurses drawing specimens because phlebotomists may not draw ICU patients or certain pediatric patients. Then the cancellation rate goes up because of the preanalytical phase.” Nurses might think they are doing the patient a favor by drawing a small sample, for example.

The study found 2.7 percent of test cancellations were due to “sample identity suspect”—even though patient identification is the Joint Commission’s No. 1 patient safety goal. “It’s disappointing that the specimen identification problem rate is still too high,” she says, noting that it seems to be a problem more or less across the board, not just with a few outliers.

Dr. Perrotta calls it “a little discouraging” that even with bar coding and other electronic systems, labs still cancel a significant number of tests because they’re not sure they are drawn from the correct patient. “That is worrisome. Some other countries may be a little ahead of us in terms of linking the specimen at the time the sample is drawn, and having solid electronic links right from the time of the draw to when it gets to the instrument.”

On the bright side, the Q-Probes study did find that a high percentage of laboratories (80 percent) require phone notification of test cancellation when it is due to preanalytical error. “That’s good, because we’ve heard from lots of clinicians and it drives them bananas to be looking for a result and to see ‘test cancelled by laboratory’ on the screen,” Dr. Darcy says. “If they’re expecting a result in an hour and then find out there’s no result, they want us to be communicating, and to be transparent and specific. There’s sometimes an impression that we’re willy-nilly cancelling things, and that’s not the case.”

Phone notification is important, Dr. Perrotta agrees. “The perception at a lot of institutions is that the lab just capriciously cancels their test for no good reason at all and they don’t understand. So our policy is that we never cancel a provider’s order without notifying them, because it also gives them the chance to address the situation earlier. A lot of times they’ll say, ‘Gee, if I’d known you didn’t have enough sample I would have done something differently, maybe get the patient back or change the treatment.’ So this is just another part of closing the loop by maintaining communication with providers, and making sure the cancellation is not unjustly labeled as the lab’s fault.”

Every test that has to be cancelled, for whatever reason, represents a wasted resource for the lab, Dr. Darcy points out. “Every lab can look at why they’re rejecting tests and then focus on places where they have the opportunity to improve.”

“Maybe it’s less waste to cancel something than it is to do a test that isn’t needed. But where there’s a patient and a specimen has to be re-collected because of a preanalytical issue—it was drawn incorrectly or didn’t get transported right away or doesn’t have a label—each of those has a potential impact on patient care. Maybe the patient is not available to have the specimen re-collected, or maybe it causes a critical delay in their care. So if it’s inappropriate orders, work on that. If it’s poorly collected specimens, work on that. If it’s still specimen ID issues, that’s important to work on, too.”

Dr. Perrotta hopes that this Q-Probes study will help laboratories share successful approaches in dealing with the persistent problem of test cancellations. “If there would be some way to tease out what are the more effective strategies labs use, that would be very helpful to people in laboratories that have tried many different things to get at these issues.”

Anne Paxton is a writer in Seattle.