Striving for Perfection

Among the powerful barriers to making progress in patient safety is an attitude of complacency induced by the rarity of serious events and the general human bias toward assuming that things will work as they are supposed to. Although the overall incidence figures for accidental injuries and deaths in healthcare are horrendous—more than 1 million preventable injuries and 44 000–98 000 preventable deaths annually (1)—because they occur in >30 million patients and are spread out over the year, significant complications in medical diagnosis and treatment are not part of the everyday experience of doctors or nurses. They are even less likely to be so among laboratory personnel. Most of the time, the system works just fine. However, even small errors can have devastating effects, and for the victim the fact that it may happen to only 1 patient in 1000 is of little solace. Two reports in this issue of Clinical Chemistry (2)(3) supply important evidence and insights on the contribution of defects in laboratory analyses that, although rare, can have serious effects. Ismail et al. (2) found only 28 false results for immunoassays performed on 5310 patients, an error rate of 0.5%. Clinicians and laboratory physicians thus rarely see an incorrect test result. However, …