Morelli P, Porazzi E, Ruspini M, Restelli U, Banfi G
Hospital of Novi Ligure, Italy.
Centre for Research on Health Economics, Social and Health Care Management (CREMS), Carlo Cattaneo University, LIUC, Castellanza, Italy.
J Prev Med Hyg. 2013 Jun;54(2):90-6.
The study objective is to evaluate critical points in the process of pre-analytical histology in an Anatomic Pathology laboratory. Errors are an integral part of human systems, including the complex system of Anatomic Pathology. Previous studies focused on errors committed in diagnosis and did not consider the issues related to the histology preparation of routine processes.
Root Cause Analysis was applied to the process of histology preparation in order to identify the root cause of each previously identified problem. The analysis started by defining an 'a priori' list of errors that could occur in the histology preparation processes. During a three-month period, a trained technician tracked the errors encountered during the process and reported them on a form. 'Fishbone' diagram and 'Five whys' methods were then applied
8,346 histological cases were reviewed, for which 19,774 samples were made and from which 29,956 histologies were prepared. 132 errors were identified. Errors were detected in each phase: accessioning (6.5%), gross dissecting (28%), processing (1.5%), embedding (4.5%), tissue cutting and slide mounting (23%), coloring, (1.5%), labeling and releasing (35%).
Root cause analysis is effective and easy to use in clinical risk management. It is an important step for the identification and prevention of errors, that are frequently due to multiple causes. Developing operators' awareness of their central role in the risk management process is possible by targeted training. Furthermore, by highlighting the most relevant points of interest, it is possible to improve both the methodology and the procedural safety.
本研究的目的是评估解剖病理学实验室分析前组织学过程中的关键点。错误是人类系统不可或缺的一部分，包括解剖病理学这个复杂系统。以往的研究主要关注诊断过程中出现的错误，而没有考虑常规流程中组织学制备相关的问题。
对组织学制备过程应用根本原因分析，以确定每个先前识别问题的根本原因。分析从定义组织学制备过程中可能出现的错误的“先验”列表开始。在三个月的时间里，一名经过培训的技术人员跟踪该过程中遇到的错误，并在表格上进行报告。然后应用“鱼骨”图和“五个为什么”方法。
共审查了8346例组织学病例，制作了19774个样本，制备了29956份组织切片。识别出132个错误。在每个阶段都检测到了错误：登记（6.5%）、大体解剖（28%）、处理（1.5%）、包埋（4.5%）、切片和贴片（23%）、染色（1.5%）、标记和发放（35%）。
根本原因分析在临床风险管理中有效且易于使用。它是识别和预防错误的重要步骤，错误通常由多种原因导致。通过有针对性的培训，可以提高操作人员对其在风险管理过程中核心作用的认识。此外，通过突出最相关的关注点，可以改进方法和程序安全性。
