Chaffe B, Glencross H, Jones J, Staves J, Capps-Jenner A, Mistry H, Bolton-Maggs P, McQuade M, Asher D
West Herts Hospitals NHS Trust, UK NEQAS BTLP, Watford, UK.
Transfus Med. 2014 Dec;24(6):335-40. doi: 10.1111/tme.12153. Epub 2014 Oct 29.
The SHOT Adverse Incident Reporting Scheme has consistently reported an unacceptably high level of errors originating in the laboratory setting. In 2006 an initiative was launched in conjunction with the IBMS, SHOT, RCPath, BBTS, UK NEQAS, the NHSE NBTC and the equivalents in Scotland, Wales and Northern Ireland that led to the formation of the UK TLC. The UK TLC in considering the nature and spread of the errors documented by SHOT concluded that a significant proportion of these errors were most likely to be related to either the use of information technology or staff education, staffing levels, skill mix, training and competency issues. In the absence of any formal guidance on these matters, the UK TLC developed a series of recommendations using the results of two laboratory surveys conducted in 2007 and 2008.
SHOT不良事件报告计划一直报告称,源自实验室环境的错误水平高得令人无法接受。2006年,与英国医学实验室科学学会(IBMS)、SHOT、皇家病理学家学会(RCPath)、英国生物化学学会(BBTS)、英国国家外部质量评估计划(UK NEQAS)、英国国民健康服务体系国家输血和组织分型中心(NHSE NBTC)以及苏格兰、威尔士和北爱尔兰的对等机构联合发起了一项倡议,促成了英国输血实验室协作组织(UK TLC)的成立。UK TLC在考虑SHOT记录的错误的性质和分布情况后得出结论,这些错误中有很大一部分极有可能与信息技术的使用或员工教育、人员配备水平、技能组合、培训和能力问题有关。由于在这些问题上缺乏任何正式指导,UK TLC利用2007年和2008年进行的两项实验室调查结果制定了一系列建议。