实验室信息系统中检验申请信息录入错误的调查分析

Analysis of the Test Request Information Input Error in Laboratory Information System

目的通过对实验室信息系统(LIS)中检验申请信息录入错误的调查分析,为实验室质量改进,满足患者和临床需要提供客观依据.方法调查本院2007年7月至12月LIS生成的常规生化报告中检验申请信息录入错误的数量、类型及录入错误率的变化.结果31734份检验报告单中检验申请信息录入错误753份(占2.37%),其中患者信息(姓名、性别、年龄)不符占2.01%,检验项目多录、少录、错录占0.20%,样本类型错误占0.11%,科室错误占0.05%.最高录入错误率为3.90%,最低录入错误率为0.99%,经过一系列改进措施6个月中的录入错误率呈下降趋势.结论实验室内分析前、分析后阶段质量保证是检验报告正确有效发出的重要环节.人员教育培训加强责任心、完善制度加强执行监管、与患者和临床医护的及时沟通,是保证报告单检验申请信息准确性的重要手段.完善LIS时,应实现分析前、分析中、分析后全程信息化管理,减少差错,促进检验流程优化和规范,提高实验室服务质量和效率,更好地为患者和临床服务.

Objective To give objective evidence for laboratory quality improvement then meet the patients＇and clinician＇s needs, through investigating the test request information input error of laboratory information system （LIS）.Methods We studied the test request information error,include the error counts, test type, and the error rate changes in routine biochemical reports of LIS from 2007.7 to 2007.12.Results There were 753 test request information errors （2.37%） in 31 734 test reports,in which the patients＇information wrong （name,sex,age） was 2.01%,test item registration error 0.20%,test type incorrect 0.11%,and the department error 0.05% .The highest error rate was 3.90%,and the lowest 0.99%,which manifested a decreasing trend gradually after taking some measures in 6 months.Conclusions The pre-analytical and post-analytical phases quality assurence could guarantee the results reported correctly and efficiently.So enhancing the personnel obligation by training,performing the rules and stre nthing supervision,and making good communications with clinical departments are important ways to guarantee the report information correctly.Meanwhile, we should obtain the pre-, intra-and post-analytical phases information management through improving LIS construction,and avoid taking mistakes,optimize the workflow,to improve laboratorial service quality and efficiency,and give the clinician and patient a better service.