Lapworth R, Teal T K
Department of Clinical Chemistry, William Harvey Hospital, Ashford, Kent, UK.
Ann Clin Biochem. 1994 Jan;31 ( Pt 1):78-84. doi: 10.1177/000456329403100113.
Blunders which occurred over a 1 year period in the clinical chemistry departments of two health districts were recorded and categorized according to type and detection stage. A blunder was defined as an incident leading to an incorrect result/set of results either being reported or detected at the final checking-out stage in the laboratory. Of the total of 120 blunders--which is a blunder rate of less than 0.1% of requests--53 (44%) were detected at the final checking-out stage. Blunders detected after the report had left the laboratory were divided into those subsequently picked up by laboratory personnel (23); those detected by clinicians (19); and those by external quality assessment schemes (21). The types of blunder were fairly equally distributed between the booking-in (36), analysis (38), and reporting (35) stages of the laboratory process. A formal review of blunders detected in laboratories is a valuable aid to overall performance.
记录了两个卫生区临床化学部门在一年时间内发生的失误，并根据类型和检测阶段进行了分类。失误被定义为导致在实验室最终检查阶段报告或检测到错误结果/结果集的事件。在总共120起失误中（失误率不到请求数的0.1%），53起（44%）在最终检查阶段被检测到。报告离开实验室后检测到的失误分为随后由实验室人员发现的（23起）；由临床医生发现的（19起）；以及由外部质量评估计划发现的（21起）。失误类型在实验室流程的登记（36起）、分析（38起）和报告（35起）阶段分布相当均匀。对实验室中检测到的失误进行正式审查对整体绩效有很大帮助。
