导致诊断错误的临床实验室测试过程中的错误的性质,原因和临床影响:一个自愿的事件报告分析
Christel van Moll1, Toine Egberts, Cordula Wagner
1From the Department of Internal Medicine, University Medical Center Utrecht.
实验室测试中的错误经常导致诊断错误,往往延误. 这项研究分析了事故报告,以了解临床实验室测试过程中的错误原因和影响.
科学领域:
- 医学错误分析 医学错误分析
- 临床实验室科学 临床实验室科学
- 患者安全研究的研究.
背景情况:
- 诊断错误,包括错过,延迟或错误的诊断,是可预防伤害的重要来源.
- 临床实验室测试过程中的错误是诊断错误的关键因素.
研究的目的:
- 调查临床实验室测试过程中错误的性质,原因和临床影响.
- 专门识别来自实验室测试问题的诊断错误.
主要方法:
- 在乌得勒支大学医学中心从2017-2018年对327个自愿事件报告的回顾性分析.
- 错误按阶段 (分析前,分析后,分析后),原因 (人,技术,组织) 和临床影响进行分类.
- 评估诊断错误的后果,特别是延迟.
主要成果:
- 分析前阶段是最常见的错误地点 (77.1%).
- 人为因素是错误的主要原因 (58.7%).
- 潜在的诊断错误发生在60%的病例中,延迟是最常见的结果 (50.5%).
结论:
- 实验室测试中的错误是潜在的诊断错误的重要原因,经常导致延误.
- 尽管有局限性,但自愿事件报告提供了与实验室流程相关的诊断错误的宝贵见解.
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