在中国一所大学医院实验室错误后的分析和行动
Ying Guo1,2, Wei Dai1,2, Yongmei Jiang1,2
1Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, No. 20, Section 3, Ren Min Nan Lu, Chengdu, 610041, Sichuan, P.R. China.
BMC health services research
|October 3, 2025
概括
实验室错误 (LE) 往往是可以预防的,大多数发生在分析之前,经常是由于实验室以外的问题. 包括技术和培训在内的有针对性的干预措施可以显著减少这些错误,并提高患者的安全性.
科学领域:
- 医学实验室科学 医学实验室科学
- 患者安全 患者安全
- 提高质量 提高质量
背景情况:
- 诊断错误是一个主要的患者安全问题,实验室医学发挥着关键作用.
- 全球对实验室错误 (LE) 的研究有限,需要研究来理解和减轻这些问题.
- 大型医院的系统因素可以放大实验室错误的影响.
研究的目的:
- 在中国一家专科医院内对实验室错误进行分类.
- 为了确定这些实验室错误的根本原因.
- 开发和评估有针对性的干预措施,以减少实验室错误和提高质量管理.
主要方法:
- 一项回顾性质量改进研究分析了从2016年3月到2023年4月的83次记录的LEs (一般和输血特异性).
- 错误按责任,测试阶段 (分析前,分析后,分析后),类型,可预防性 (认知与非认知) 和患者影响分类.
- 追踪了根本原因分析和纠正措施,干预措施包括工作流程优化,员工培训和LIS升级.
主要成果:
- 分析前阶段最容易出现错误 (51%),主要是由于样本采集和请求程序.
- 错误的很大一部分来自实验室之外 (60%),认知错误是高度可预防的.
- 干预措施,包括LIS升级和改进的通信,使预分析错误在成本效益方面大幅减少.
结论:
- 预分析错误是最常见的LEs,通常源于实验室外因素.
- 包括技术,工作流程简化,培训和沟通在内的有针对性的干预措施有效地减少了LEs.
- 持续监测和特定环境的策略对于实验室质量管理至关重要,特别是在大型医疗保健系统中.
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