MONITORING PRE-ANALYTICAL INCIDENTS AS A TOOL FOR RISK MANAGEMENT AND PATIENT SAFETY IN A UNIVERSITY HOSPITAL LABORATORY

Introduction:
The pre-analytical phase is recognized as the most vulnerable step of the total testing process, accounting for the majority of laboratory errors. Failures occurring during patient identification, specimen collection, labeling, transportation, and sample handling may compromise test reliability and negatively affect patient safety. Continuous monitoring of pre-analytical incidents is therefore an essential component of laboratory risk management and quality improvement programs.

Objective:
To describe the main pre-analytical incidents identified in healthcare and laboratory sectors of a tertiary university hospital in southern Brazil and to highlight improvement strategies aimed at enhancing patient safety and laboratory quality.

Methods:
A retrospective descriptive study was conducted using reports recorded by the laboratory risk management working group between January and May 2026. Incidents involving patient misidentification were not assessed and were not included in the analysis. Data were obtained from internal notifications related to the flow of biological specimens across healthcare and laboratory sectors. Pre-analytical incidents were classified and analyzed according to frequency.

Results:
During the study period, the laboratory processed 1,403,233 tests and recorded 173 reportable incidents, of which 62 (35.8%) were classified as pre-analytical. The most frequent events were failures in specimen reception (n=16; 25.8%), delays in specimen collection (n=9; 14.5%), specimen collection in inappropriate tubes (n=8; 12.9%), mislabeled specimens (n=5; 8.1%), and failures in sample cancellation procedures (n=4; 6.5%). These findings revealed vulnerabilities in the pre-analytical workflow and highlighted opportunities for process standardization and staff training. The identified incidents supported the development of corrective and preventive actions, including review of pre-analytical procedures and targeted training initiatives.

Conclusions:
Systematic monitoring of pre-analytical incidents, supported by continuous education, process review, and risk management strategies, contributes to error reduction, improves patient safety, and strengthens the culture of quality within healthcare organizations.