Savoca Reto
Zentrallabor, Spitäler Schaffhausen.
Ther Umsch. 2015 Feb;72(2):113-8. doi: 10.1024/0040-5930/a000652.
More than half of the so called "laboratory errors" has already happened before the analysis starts in the laboratory and many mistakes are made after the analysis itself. Pre- and post-analytical errors cause 60 to 90 % of all unexpected or erroneous values; only 10 to 15 % are caused by analytical problems. Internal quality control and external quality assessments are a matter of course today while standardisation still could be improved. The pre- and post-analytical processes however are only scarcely supervised. Good patient preparation, reliable patient identification and correct blood draws still cannot be taken for granted - improved training and education are necessary. There is also room for improvement in the communication of the results and the implementation of the consequences thereof. Errors in all phases of the analytical process contain valuable clues for optimisations. An improved culture of failure management would allow tapping the full potential of these clues.
超过一半的所谓“实验室误差”在实验室分析开始前就已经发生,而且许多错误是在分析过程之后出现的。分析前和分析后的误差导致了所有意外或错误值的60%至90%;只有10%至15%是由分析问题造成的。如今,内部质量控制和外部质量评估是理所当然的事情,而标准化仍有改进的空间。然而,分析前和分析后的过程几乎没有受到监督。良好的患者准备、可靠的患者识别和正确的采血仍不能被视为理所当然——需要加强培训和教育。在结果沟通及其后果的落实方面也有改进的余地。分析过程所有阶段的误差都包含着优化的宝贵线索。改进的失误管理文化将有助于充分利用这些线索的潜力。