Howanitz P J, Walker K, Bachner P
Department of Pathology and Laboratory Medicine, University of California, Los Angeles Medical Center 90024-1713.
Arch Pathol Lab Med. 1992 Jul;116(7):694-700.
Over a 3-month period, 61,496 errors were detected in clinical laboratory reports by 631 participants in the College of American Pathologists' 1990 Q-Probes program. Each error detected was defined as an opportunity for improvement. Almost 4% of the detected errors were attributed to nonlaboratory personnel and approximately 4% (A errors) had a major impact on patient care. Rates of B (serious errors, but unlikely to affect patient care) and C errors (minor clerical errors) were approximately equal. When expressed in terms of measures of laboratory work loads, four of six measures of mean errors were lowest in blood banking, intermediate in chemistry and microbiology, and highest in hematology. Thirteen percent of participants did not have an error detection system in place. We conclude that many errors go undetected, and we recommend that an effective system for error detection in patient reports should be employed in all laboratories.
在为期3个月的时间里,美国病理学家学会1990年Q-Probes项目的631名参与者在临床实验室报告中检测到61496处错误。每一处检测到的错误都被定义为一个改进机会。几乎4%的检测到的错误归因于非实验室人员,约4%(A类错误)对患者护理有重大影响。B类(严重错误,但不太可能影响患者护理)和C类错误(轻微文书错误)的发生率大致相等。以实验室工作量指标来表示时,平均错误的六项指标中有四项在血库中最低,在化学和微生物学中居中,在血液学中最高。13%的参与者没有错误检测系统。我们得出结论,许多错误未被发现,我们建议所有实验室都应采用有效的患者报告错误检测系统。