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[一家医院急诊临床实验室中九项质量指标的实施]

[Implementation of nine quality indicators in a hospital emergency clinical laboratory].

作者信息

Guzmán D Ana María, Sánchez P Tomás, DE LA Barra D Ricardo, Madrid Q Angélica, Quiroga G Teresa

机构信息

Departamento de Laboratorios Clínicos, Pontificia Universidad Católica de Chile, Santiago, Chile.

出版信息

Rev Med Chil. 2011 Feb;139(2):205-14. Epub 2011 Jul 11.

PMID:21773658
Abstract

BACKGROUND

Quality indicators are tools used to monitor specific activities within a process and improve it. In the area of clinical laboratories, the National Accreditation Standards for Providers of Health and the ISO 15189 standard recommend the implementation of indicators that monitor the test cycle with emphasis on those that contribute to a safer health care.

AIM

To describe the implementation of nine indicators in a hospital clinical laboratory and their measurement during one year.

MATERIAL AND METHODS

The indicators implemented and measured were four of the pre-analytical phase (number of rejected samples, times of transport, blood culture contamination and blood cultures inoculated with adequate blood volumes), two of the analytical phase (coherence of Gram stains of blood culture with microorganism cultured and correct results in external quality control surveys) and three of the post-analytical phase (compliance with order to report lapse goals, corrected reports and alert values report).

RESULTS

Two indicators of pre-analytical phase did not meet the per determined targets: number of rejected samples and blood cultures inoculated with adequate blood volume. All indicators of the analytical and post analytical phases were within the pre-determined targets.

CONCLUSIONS

Coordinated work should be initiated especially with the nursing service to correct the two indicators that did not meet the target. The incorporation of quality indicators to monitor critical processes within the laboratory was undoubtedly an opportunity to identify areas for improvement.

摘要

背景

质量指标是用于监测过程中的特定活动并对其进行改进的工具。在临床实验室领域,《健康服务提供者国家认可标准》和ISO 15189标准建议实施监测检测周期的指标,重点关注那些有助于提高医疗安全性的指标。

目的

描述某医院临床实验室九个指标的实施情况及其在一年内的测量结果。

材料与方法

所实施和测量的指标包括分析前阶段的四个指标(拒收样本数量、运输次数、血培养污染以及接种血量充足的血培养)、分析阶段的两个指标(血培养革兰氏染色与培养微生物的一致性以及外部质量控制调查中的正确结果)和分析后阶段的三个指标(符合报告延迟目标、修正报告以及危急值报告)。

结果

分析前阶段的两个指标未达到既定目标:拒收样本数量和接种血量充足的血培养。分析阶段和分析后阶段的所有指标均在既定目标范围内。

结论

应特别与护理服务部门开展协同工作,以纠正未达标的两个指标。纳入质量指标以监测实验室中的关键流程无疑是识别改进领域的契机。

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