Fabbretti G
Surgical Pathology Unit, Department of Clinical Pathology and Radiology, Infermi Hospital, Rimini, Italy.
Pathologica. 2010 Jun;102(3):96-101.
Because of its complex nature, surgical pathology practice is prone to error. In this report, we describe our methods for reducing error as much as possible during the pre-analytical and analytical phases. This was achieved by revising procedures, and by using computer technology and automation. Most mistakes are the result of human error in the identification and matching of patient and samples. To avoid faulty data interpretation, we employed a new comprehensive computer system that acquires all patient ID information directly from the hospital's database with a remote order entry; it also provides label and request forms via-Web where clinical information is required before sending the sample. Both patient and sample are identified directly and immediately at the site where the surgical procedures are performed. Barcode technology is used to input information at every step and automation is used for sample blocks and slides to avoid errors that occur when information is recorded or transferred by hand. Quality control checks occur at every step of the process to ensure that none of the steps are left to chance and that no phase is dependent on a single operator. The system also provides statistical analysis of errors so that new strategies can be implemented to avoid repetition. In addition, the staff receives frequent training on avoiding errors and new developments. The results have been shown promising results with a very low error rate (0.27%). None of these compromised patient health and all errors were detected before the release of the diagnosis report.
由于手术病理学实践的性质复杂,容易出现差错。在本报告中,我们描述了在分析前和分析阶段尽可能减少差错的方法。这是通过修订程序、使用计算机技术和自动化来实现的。大多数错误是在患者和样本的识别与匹配过程中人为失误造成的。为避免错误的数据解读,我们采用了一种全新的综合计算机系统,该系统通过远程订单录入直接从医院数据库获取所有患者身份信息;它还通过网络提供标签和申请表,在送检样本前需要填写临床信息。在进行外科手术的地点直接且立即对患者和样本进行识别。在每一步都使用条形码技术输入信息,并对样本块和玻片采用自动化操作,以避免手工记录或传递信息时出现的错误。在流程的每一步都进行质量控制检查,以确保没有任何一步存在侥幸心理,且任何阶段都不依赖于单个操作人员。该系统还提供差错的统计分析,以便能够实施新的策略来避免重复发生。此外,工作人员会经常接受关于避免差错和新进展的培训。结果显示出了令人满意的成果,差错率非常低(0.27%)。这些差错均未危及患者健康,并且在诊断报告发布前所有差错都被检测到了。