临床实验室测试过程中的诊断错误:对患者安全的发生率和影响 - - 一份为期3年的自愿事件报告分析
Montri Saengpattrachai1, Nuntaga Juntararat1, Unchalee Wittayapipat1
1Total Quality and Cost Improvement Division, Bangkok Hospital Headquarters, Thailand.
概括
实验室诊断错误,主要发生在分析前阶段,发生率为2.9%. 大多数错误都源于人为因素,对患者的诊断或伤害的影响很小,这凸显了系统级安全策略的必要性.
科学领域:
- 医学诊断 医学诊断 医学诊断
- 实验室医学 实验室医学
- 患者安全 患者安全
背景情况:
- 实验室过程中的诊断错误造成了严重的患者安全风险.
- 这些错误与不良的临床结果和诊断问题有关.
- 了解这些错误的频率和影响对于改善医疗保健至关重要.
研究的目的:
- 为了确定与实验室相关的诊断错误的频率和类型.
- 评估这些错误对临床诊断和患者伤害的影响.
- 评估泰国医院网络中的组织声誉影响.
主要方法:
- 在三年 (2021-2023) 期间,对诊断错误的回顾性分析.
- 数据来源于曼谷医院总部的自愿事件报告系统.
- 用于分类错误,确定原因和评估临床影响的描述性统计数据.
主要成果:
- 在5,951,783个处理样本中发现2.9%的诊断错误率.
- 分析前的错误 (89.2%),主要是错误的测试订单和样本采集,占主导地位.
- 人类因素造成了91.1%的错误;大多数都没有影响诊断或伤害患者.
结论:
- 需要全面的系统级战略来解决实验室中人为因素的脆弱性.
- 简化实验室工作流程可以提高诊断准确度.
- 实施基于证据的战略是促进临床实验室过程中患者安全的关键.
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