檢體采集作業(yè)流程病人同意課件

謝文祥

檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)謝文祥檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)2013Hospital

NationalPatientSafety

GoalsIdentifypatientcorrectlyImprovestaffcommunicationUsemedicinessafelyPreventinfectionCheckpatientmedicinesIdentifypatientsafetyrisksPreventmistakesinsurgeryTheJointCommissionAccreditationHospital2013Hospital

NationalPatient2013Laboratory

NationalPatientSafetyGoalsIdentifypatientcorrectlyImprovestaffcommunicationPreventinfectionTheJointCommissionAccreditationLaboratory2013Laboratory

NationalPatien年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目標(biāo)1.避免藥物錯(cuò)誤1.提升用藥安全1.提升用藥安全2.落實(shí)院內(nèi)感染控制2.落實(shí)院內(nèi)感染控制2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.杜絕手術(shù)錯(cuò)誤、病人錯(cuò)誤及手術(shù)程序錯(cuò)誤3.提升手術(shù)正確性3.提升手術(shù)正確性4.避免病人辨識(shí)錯(cuò)誤4.提升病人辨識(shí)的正確性4.提升病人辨識(shí)的正確性5.預(yù)防病人跌倒5.預(yù)防病人跌倒5.預(yù)防病人跌倒6.鼓勵(lì)異常事件通報(bào)6.鼓勵(lì)異常事件通報(bào)7.改善交接病人之溝通與安全8.提升民眾參與病人安全TaiwanJointCommissiononHospitalAccreditation

年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.提升手術(shù)安全4.預(yù)防病人跌倒及降低傷害程度5.鼓勵(lì)異常事件通報(bào)及資料正確性6.提升醫(yī)療照護(hù)人員間溝通的有效性7.鼓勵(lì)病人及其家屬參與病人安全工作8.提升管路安全TaiwanJointCommissiononHospitalAccreditation2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全Taiwan2010-2011年度目標(biāo)的演進(jìn)提升用藥安全落實(shí)醫(yī)療機(jī)構(gòu)感染控制

提升手術(shù)安全預(yù)防病人跌倒及降低傷害程度鼓勵(lì)異常事件通報(bào)及資料正確性

提升醫(yī)療照護(hù)人員間溝通的有效性鼓勵(lì)病人及其家屬參與病人安全工作提升管路安全加強(qiáng)醫(yī)院火災(zāi)預(yù)防與應(yīng)變TaiwanJointCommissiononHospitalAccreditation2010-2011年度目標(biāo)的演進(jìn)提升用藥安全TaiwanObjectivesIdentifythesignificantpre-analyticalerrorsthatcanoccurduringbloodspecimencollectionandtransport.Explainthevariousmeansofpre-analyticalerrorprevention.Listproactivestepstoreducepotentialpre-analyticalerrorsassociatedwithbloodcollectionandtransport.ObjectivesIdentifythesignifiIntroductionThreephasesoflaboratorytesting:pre-analytical,analytical,post-analyticalPre-analytical:specimencollection,transportandprocessingAnalytical:testingPost-analytical:testingresultstransmission,interpretation,follow-up,retestingIntroductionThreephasesoflPhlebotomyErrorsPhlebotomyisahighlycomplexskillrequiringexpertknowledge,dexterity,andcriticaljudgmentItisestimatedthatonebillionvein-puncturesareperformedannuallyintheU.S.PhlebotomyErrorsmaycauseharmtopatientsorresultinneedle-stickinjurytothePhlebotomistPhlebotomyErrorsPhlebotomyisPre-analyticalerrorsPre-andpost-analyticalerrorsareestimatedtoconstitute90%oferrorsErrorsatanystagesofthecollection,testingandreportingprocesscanpotentiallyleadtoaseriouspatientmisdiagnosisErrorsduringthecollectionprocessarenotinevitableandcanbepreventedwithadiligentapplicationofqualitycontrol,continuingeducationandeffectivecollectionsystemsPre-analyticalerrorsPre-andTypesofcollectionerrorsPatientIdentificationPhlebotomyTechniqueTestCollectionProceduresSpecimenTransportSpecimenProcessingTypesofcollectionerrorsPatiPatientIdentificationErrorsErrorsincorrectlyidentifyingthepatientareindefensibleReasonsforpatientidentificationerrors:ProperpositivepatientidentificationproceduresnotfollowedPatientidentificationfromidentificationbracelet(inpatients)Patientidentificationbyaskingpatienttostateorspelltheirfullname(inpatients/outpatients)Patientidentificationbystafforfamilymemberifpatientunabletoidentifyhim/herselfPatientIdentificationErrorsEPatientIdentificationErrorsSpecimentubesunlabeled:RequisitionorcollectiontubelabelsnotaffixedtotubesRequisitionorcollectiontubelabelsinbagcontainingcollectiontubesRequisitionorcollectiontubelabelsrubber-bandedtotubesCollectiontubelabelsnotaffixedtoalltubesSpecimencollectiontubeslabeledinsufficientlywithatminimumpatient’sfullname,date/timeofcollection,phlebotomist’sinitialsPatientIdentificationErrorsSPatientIdentificationErrorsCollectiontubeslabeledwiththewrongpatientWrongcomputerizedlabelsaffixedtocollectiontubesatbedsideCollectiontubesnotlabeledatthetimeofcollectionCollectiontubesincorrectlylabeledbysomeoneotherthanthephlebotomistwhocollectsthespecimenPatientIdentificationErrorsCPatientComplicationsSomepatientvariablesthataffectbloodspecimensDietFastingExerciseObesityAllergiestoalcoholoriodineusedtocleanvein-puncturesiteUsealternativecleansersuchaschlorhexidinPatientComplicationsSomepatiPhlebotomyTechniqueErrorsPhlebotomytechniqueisimportantEnsurestestresultvalidityMinimizestraumatopatientMinimizespotentialforphlebotomistinjuryReducesrecollectionsVeinselectionessentialforsuccessfulVein-punctureThreeveinsinantecubitalfossainorderofselection(1)mediancubital(2)cephalic(3)basilicPhlebotomyTechniqueErrorsPhlPhlebotomyTechniqueErrorsSiteSelectionAvoidsiteswithIVUsealternativearmordrawbelowIVtoavoidcontamination/dilutionfromIVDocumentarmifIVMastectomy—avoidsiteduetolymphostasisInfectionrisk/alterationinbodyfluidsandbloodanalytesEdematousareas—avoidduetoaccumulationofbodyfluidsPossiblecontamination/dilutionofspecimenPhlebotomyTechniqueErrorsSitPhlebotomyTechniqueErrorsVenousAccessDifficultiesObstructed,hardened,scarredveinsVeinsdifficulttolocateUseofAlternativesitesTopofhand/SideofwristAreastoavoidVeinCollapseUseofappropriateneedlesizeSmallerevacuatedcollectiontubePhlebotomyTechniqueErrorsVenPhlebotomyTechniqueErrorsTourniquetApplicationTourniquettiedtooclosetothevenipuncturesitecancausehematomaVeinsmaynotbecomeprominentiftourniquetistiedtoohigh(morethan3to4inchesabovevenipuncturesite)Tourniquetleftonlongerthanoneminutecanresultinhemoconcentration,affectingsometestresultsTourniquetshouldbereleasedassoonasneedleisinthelumenoftheveinandbloodflowestablishedPhlebotomyTechniqueErrorsTouPhlebotomyTechniqueErrorsCleansingofvenipuncturesiteThoroughcleaningwithalcoholAllowalcoholtodrycompletelytoavoidstingingsensationuponneedleentryandhemolysisofsampleSamplessuchasbloodculturesshouldbecollectedusingiodinetocleansesitetoensuresterilityofsampleRecollectionrateforbloodculturesrangesduetocontaminationisashighas50%inhospitalswithincreasedcosts,patientovertreatmentPhlebotomyTechniqueErrorsClePhlebotomyTechniqueErrorsCorrectcollectionsystemEvacuatedtubesystem(Vacutainer)forlargeveinsinantecubitalfossaSyringeforsmall,fragileveinsorveinsoutsideantecubitalfossaVenousaccessNeedleentryshouldbeat15to30degreesdependingondepthofveinNeedleentryshouldbeinsamedirectionasvein,centeredoverveinAnchorveintopreventmovementduringneedleentryandtoreducepaintopatientPhlebotomyTechniqueErrorsCorTestCollectionErrorsOrderofDrawOrderofdrawaffectsthequalityofthesampleandcanleadtoerroneoustestresultsduetocontaminationwiththeadditivefromthepreviousbloodcollectiontubeHemolysisBloodcollectedinsufficienttoamountofadditiveintubeTraumaticvenipunctureBloodcollectedfromareawithhematomaVigorousshakingoftubesaftercollectionMilkingthesitewhencollectingcapillarysamplesandbloodcollectedusingasmalldiameterneedle

TestCollectionErrorsOrderofTestCollectionErrorsTimingoffCollectionTimedDrawsTherapeuticDrugMonitoringPeakandtroughcollectiontimesBasalStateCollectionsFastingrequirements—nofoodorliquidexceptwaterSpecimensaffectedbytimeofday,forexample,cortisolTestCollectionErrorsTimingoTestCollectionErrorsImpropercollectiontubedrawnfortestorderedCollectiontubenotcompletelyfilledExample—lightbluetoptubeforCoagulationStudies.IncompletefillingresultsinspecimendilutionanderroneousProthrombinandaPTTtestresultsTestCollectionErrorsImproperTestCollectionErrorsCapillaryCollections—fingerstickorheelstickAppropriatesiteHeelstick—sidesofthebottomsurfaceoftheheelFingerstick—thirdorfourthfingers,perpendiculartofingerprintlinesonfleshypadsonfingersurfaceWarming—WarmbeforecollectiontoincreasecapillarybloodflownearskinsurfaceCleaning—cleansesitewithalcoholandallowtoairdryTestCollectionErrorsCapillarCapillaryCollectionsMassagingsitetoincreasebloodflowMilkingsitecancausehemolysisortissuefluidcontaminationFingersticks—rollfingerstowardfingertipat1stfingerjointseveraltimesHeelsticks—gentlysqueezeinfant’sheelbeforeperformingpuncture.PerformpuncturewhilefirmlysqueezingfingerorheelWipeawayfirsttwodropsofbloodEnsurethatfullblooddropwellsupeachtimeCapillaryCollectionsMassagingCapillaryCollectionsAvoidtouchingcapillarycollectiontubeormicrocollectiontubetoskinorscrapingskinsurfaceContaminatespuncturesiteBloodmaybecomehemolyzedMixingmicrocollectiontubeswithadditivefrequentlytoavoidmicroclotsCollectingtubeswithadditivesfirstProtectingtubesforbilirubinfromlightCapillaryCollectionsAvoidtouGoodSampleHandlingDrawthecorrectvolumeMix:It’sessentialAllowtimetoclotSpinunderthecorrectconditionsAspirate,Don’tpourRefertotheproductinsertorpackagelabelingsuppliedbythemanufactureofanybloodcollectionproductforcompleterecommendationsonsamplecollectionandprocessingReference:CLSI(H3-A6)2008/CLSI(H18-A3)2004

GoodSampleHandlingDrawthecBloodSpecimenTransportErrorsTransportofbloodspecimensinthepropermanneraftercollectionensuresthequalityofthesampleTimingSomespecimensmustbetransportedimmediatelyaftercollection,forexampleArterialBloodGases.SpecimensforserumorplasmachemistrytestingshouldbecentrifugedandseparatedwithintwohoursBloodSpecimenTransportErrorTransportErrorsTemperatureSpecimensmustbetransportedattheappropriatetemperaturefortherequiredtestOnice—ABGs,AmmoniaWarmed--98.6degrees(37C),cryoglobulinsAvoidtemperatureextremesiftransportedfromviavehiclefromothercollectionsiteTransportContainerSomesamplesneedtobeprotectedfromlight,forexample,bilirubinTransportinleak-proofplasticbagsinlockablerigidcontainersTransportErrorsTemperatureErrorPreventionPhlebotomyEducationPhlebotomistsshouldhavecompletedastandardacademiccourseinphlebotomyandundergothoroughon-the-jobtrainingunderthesupervisionofaseniorphlebotomistContinuingEducationPhlebotomistsshouldparticipateinregulareducationalcompetencyassessments(writtenandobservational)ProfessionalLicensurePhlebotomyStaffingAdequatestaffingtomaintaincollectionstandardsTechnologyUseofbarcodescannersforpatientidentificationErrorPreventionPhlebotomyEduQuestionsandDiscussionHowarepre-analyticalerrorspreventedinyourlaboratory?Whattechnologydoyouusetopreventhumanerror?Whatsystemsdoesyourhospitalusetopreventerrorsbynon-laboratorystaffcollectingblood?Whatpro-activeimprovementswouldreducethenumberofpre-analyticalerrors?QuestionsandDiscussionHowar檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？病人辨識(shí)：原則、方法(時(shí)機(jī)、頻率)病人保護(hù)：隱私、安全(消毒、暈針)衛(wèi)教說明：口頭、單張、媒體、手冊(cè)正確採集：檢體量、檢體種類保存?zhèn)魉停罕４鎰?抗凝劑)、溫度、包裝檢體訂定允收原則的必要與省思？檢體重採的限制與省思？TaiwanHospitalAssociation2007檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？TaiwanHo檢驗(yàn)前流程(程序)Pre-examinationProcedure(Process)檢驗(yàn)前流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)SamplingIdentificationBarcodelabelingSingletube(CloseContainerSystem)InsideAliquot(Auto-Centrifugation)TLA(Auto-Transportation)EfficiencyandEffectiveness

案例一病人晚上掛急診，白血球(WBC)報(bào)告為630，第二天上午主治醫(yī)師請(qǐng)CCU再追蹤一次WBC，病人的報(bào)告為17530，因兩次報(bào)告差異大，所以CCU專科護(hù)理師打電話至檢驗(yàn)科，請(qǐng)醫(yī)檢師重驗(yàn)前一天於急診所驗(yàn)的WBC，但醫(yī)檢師表示因當(dāng)時(shí)所抽的血量不夠，無法再重驗(yàn)，所以也無法確認(rèn)前一天急診WBC報(bào)告是否正確?案例一病人晚上掛急診，白血球(WBC)報(bào)告為630，第二天抽錯(cuò)病人編號(hào)錯(cuò)誤(貼錯(cuò)標(biāo)籤)血液稀釋血液凝固用錯(cuò)試管(抗凝劑錯(cuò))操作錯(cuò)誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報(bào)告填錯(cuò)抽錯(cuò)病人案例二病人因頭部鈍傷，頭暈至急診就醫(yī)，醫(yī)師診視後，給予打上點(diǎn)滴，抽CBC、生化檢驗(yàn)，隨後醫(yī)檢師通報(bào)危險(xiǎn)值，告知醫(yī)師血紅素3.8，詢問病人表示平時(shí)無貧血癥狀且還有在捐血，故依照醫(yī)矚再抽第二次CBC，血紅素:13.3?案例二病人因頭部鈍傷，頭暈至急診就醫(yī)，醫(yī)師診視後，給予打上點(diǎn)抽錯(cuò)病人編號(hào)錯(cuò)誤(貼錯(cuò)標(biāo)籤)血液稀釋血液凝固用錯(cuò)試管(抗凝劑錯(cuò))操作錯(cuò)誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報(bào)告填錯(cuò)抽錯(cuò)病人檢驗(yàn)流程(程序)ExaminationProcedure(Process)檢驗(yàn)流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)CalibrationInternalQualityAssessment(QC)ExternalQualityAssessment(PT)EfficiencyandEffectiveness

案例三於03：53抽血aPTTdata180.4sec，當(dāng)時(shí)血液室電話告知通報(bào)危險(xiǎn)值，護(hù)理人員立即告知主治醫(yī)師及住院醫(yī)師，主治醫(yī)師立即囑輸注FFP2UIVDst、vitK11ampIVDst，並請(qǐng)住院醫(yī)師追蹤aPTTprolong原因，住院醫(yī)師詳細(xì)評(píng)估後，囑recheckaPTT、PTdata，表示第二次追蹤若真的是有延長情形，預(yù)備檢驗(yàn)其他凝血功能。於05：39再驗(yàn)結(jié)果aPTT34.7sec、PT14.4sec（抽血時(shí)尚未執(zhí)行FFP及K1醫(yī)囑），電話詢問血液室人員為何兩次檢驗(yàn)數(shù)值差距大?檢驗(yàn)室人員才表示第一次檢驗(yàn)數(shù)值是因?yàn)闄C(jī)臺(tái)故障（未主動(dòng)告知SICU），故第二次檢驗(yàn)數(shù)值才以人工計(jì)數(shù)執(zhí)行。[如何發(fā)現(xiàn)機(jī)臺(tái)故障，補(bǔ)救程序?yàn)楹?]案例三於03：53抽血aPTTdata180.4se抽錯(cuò)病人編號(hào)錯(cuò)誤(貼錯(cuò)標(biāo)籤)血液稀釋血液凝固用錯(cuò)試管(抗凝劑錯(cuò))操作錯(cuò)誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報(bào)告填錯(cuò)抽錯(cuò)病人案例四病人3/28由ER入,因H/D3/30轉(zhuǎn)床,病人CPK、CK-MB、Troponin-I一直偏高所以