The Science Of Mistakes In A Healthcare Setting. Are We Immune From COVID Testing Errors In Aotearoa New Zealand?

The recent issue with incorrect COVID PCR result text messages being sent out from SydPath, St. Vincent's Pathology in Sydney raises a valid question. Could this happen in Aotearoa New Zealand? The logical reality is that mistakes can and do happen no matter how careful we all are.

As a profession that works closely with our Australian colleagues, we do all feel the pain when things go wrong. It is never a good feeling to identify that a major mistake has been made. The continuing theme highlighted worldwide is that diagnostic laboratory services have been underfunded and the staff undervalued and treated poorly for many years prior to the COVID pandemic. Pathology services have suffered from a lack of profile and governance representation in most countries and without exception been the poor cousins of essential frontline medical services. Roll the clock forward to 2022 and it is fair to say that is slowly starting to change but there is a long way to go. However, this should not be viewed as an excuse for errors as many other health services have had the same pandemic pressure.

In Aotearoa New Zealand there are strict diagnostic laboratory protocols to maintain international accreditation standards coupled with stringent and comprehensive scientist and technician training, competency, and professional development requirements to gain Medical Registration and an Annual Practising Certificate (APC). Our diagnostic laboratory workforce is regulated and monitored to an extent not seen in many other comparable countries. For example, in Australia, the medical laboratory workforce has no regulatory requirement to be registered health professionals with an APC nor perform regular professional development. We are very fortunate to be recognised in this way by the various national health acts in place.

‘Rather than overregulate the consumables and kits we use, in Aotearoa New Zealand we register and empower our laboratory professionals, so they are able to assess, verify and validate the methodology and testing that is performed’ says Terry Taylor the New Zealand Institute of Medical Laboratory Science (NZIMLS) president.

Does all of this mean we won’t make any errors? The answer is a resounding no! We can only mitigate the risk and ensure our systems are under constant audit and review. When mistakes are made it never helps for bricks to be thrown from armchair experts who have no clinical laboratory experience or context of what the actual issues are that led to an error happening.

‘It needs to be remembered that our diagnostic laboratories routinely perform a full spectrum of hundreds of different tests every day, for example COVID testing may only make up 10-15% of our total daily workload at present. The irony is that our laboratory performance is almost exclusively judged by numbers and turnaround times for COVID testing alone’, says Terry Taylor.

‘The past 21 months have highlighted the dedication and drive of our medical laboratory staff but have also exposed the lack of national coordination and future proofing caused by years of underfunding and neglect due to a variety of reasons outside the profession’s control. Our laboratory service providers have done a sterling job in the face of many challenges and for us to mount the COVID testing response we have is a credit to all those hard working and innovative staff’, says Terry Taylor.

One of the common statements from those in governance is that all the measures we have in place to combat the COVID spread are designed to prevent our frontline hospital services from being overrun. There has been particular emphasis on intensive care and high dependency unit capability. Yet as we have seen in Australia, the UK and the USA, it has been perfectly acceptable to totally swamp other frontline line health services such as diagnostic laboratory services in this push. This is without understanding or appreciating that an overwhelmed laboratory service has a significant effect on diagnostic services for those critical care patients and the medical staff working to save them.

There are tough decisions to be made on what our future national COVID testing plan is as we move into 2022. Our laboratories have been quietly and efficiently working on building up COVID PCR testing capacity to the region of 60, 000 tests nationally per day. While this is admirable this also comes at a cost to a lot of the other laboratory services provided, particularly during surge events. This will put even more strain on a beleaguered and weary workforce that has basically been on edge for nearly two years.

‘Everyone knows that when people are at their most tired and weary that more mistakes start to creep into everyday tasks. We need to ensure that there is a clear plan of rotation, freshening up and positive encouragement to keep our workforce performing at their current standard’, says Terry Taylor.

‘To achieve this there needs to be a clear testing plan for how to deal with the spread of the virus into the community. Omicron has clearly bought a new edge and urgency to this. How and who we test must be front and centre and clearly communicated by health and political leaders to prevent service bottlenecks’, says Terry Taylor.

‘To suddenly put excessive pressure on and exceed our testing capacity in the current environment is a potential perfect storm that will ultimately lead to mistakes and pressures that everyone will find difficult to deal with. We only need to look overseas for the bedlam that this will cause for our wider health system’, says Terry Taylor.

So, the simple answer is yes there is always potential for testing mistakes to occur. In many cases mistakes are found to be a symptom of a much bigger underlying issue. I implore everyone to be mindful of the intense pressure that many of the frontline health services have been under as the pandemic continues into 2022. It is worth remembering we are yet to see that perfect living human that has never made an error of judgment or a mistake in either life or their chosen profession.

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