The Cost of Pre-Analytical Errors in INR Testing at a Tertiary-Care Hospital Laboratory: Potential for Significant Cost Savings.

BACKGROUND: Preanalytical errors account for most laboratory errors. Although the frequencies of preanalytical errors are well characterized in the literature, little is known regarding the costs of these errors to the laboratory. OBJECTIVE: To analyze costs associated with preanalytical errors associated with the international normalized ratio (INR) test. METHODS: We performed a retrospective analysis of INR requests associated with preanalytical error codes from January 2009 through September 2013. Preanalytical error types were those related to order entry (no specimen collected) and those unrelated to order entry (insufficient specimen quantity or specimen-integrity concerns). We calculated the cost of analysis of a specimen and the cost of investigating errors. RESULTS: During the study period, there were 557,411 INR requests, 13.1% of which were associated with a preanalytical error code. The total annual cost of INR testing was USD $379,222.50. Investigation and reporting of preanalytical errors not related to order entry represented 10.5% of our annual INR testing budget (USD $39,939.00). CONCLUSIONS: Minimizing preanalytical errors has the potential to result in significant cost savings.

Continuous nonfluoroscopic localization of the esophagus during radiofrequency catheter ablation of atrial fibrillation.

INTRODUCTION: Atrial-esophageal fistula formation is a dreaded complication of radiofrequency catheter ablation for atrial fibrillation. Esophageal localization is of potential value in avoiding lesion placement where the left atrium is juxtaposed to the esophagus. METHODS AND RESULTS: Twenty-seven patients underwent 33 pulmonary vein encirclement procedures. All the patients received general anesthesia with inhalational agents and either a fenestrated laryngeal mask airway or an endotracheal tube. A diagnostic electrophysiologic catheter was inserted into the esophagus, and a virtual esophageal tube was created using an electroanatomic mapping system. In all cases, the catheter was placed without difficulty and satisfactory virtual esophageal images were created. The catheter remained in the esophagus until the end of each ablation procedure. Esophageal catheter location during and after the ablation was compared with the initial location. Areas of close proximity between the left atrium and esophagus were easily identified. Change in esophageal location was not observed. Identification of esophageal proximity to the pulmonary veins allowed for identification of high-risk cases. In such cases, the planned procedure was modified to avoid esophageal injury (12 of 27 patients). CONCLUSIONS: (1) Real-time localization of esophageal position using a nonfluoroscopic mapping system during atrial fibrillation ablation is safe, practical, and straightforward. (2) Among patients who receive general anesthesia, esophageal position appears to be static, suggesting that one initial virtual image is sufficient for the duration of an ablation procedure.