持续评估能力验证试验中未通过的项目,不断提升门急诊检验质量

Continuous evaluation on the unpassed items in proficiency testing and improvement on the determination quality of outpatient department and emergency department

目的通过持续评估能力验证试验(PT)未通过的项目,提升门急诊检验室的检验质量,为临床提供准确的报告。方法通过分析美国病理家学会(CAP)PT的反馈报告,对每一份未通过PT的结果进行评估,对出现的问题予以调查、分析和整改,并将改进内容充实到以后的质量管理计划中达到持续质量改进,如此不断循环。结果连续5年门急诊检验参加PT测试数和未通过率分别为2007年2 440次、2.6%,2008年2 593次、1.1%,2009年2 355次、0.6%,2010年1 894次、0.5%,2011年1 799次、0.4%;5年间未通过率比较差异有统计学意义(P<0.05)。未通过的主要原因为方法学问题、技术问题和文书问题。结论 5年来PT未通过率明显下降,按照CAP认可的质量管理体系制定的整改措施有利于质量的持续改进和提高。

Objective To evaluate continuously the unpassed items in proficiency testing （PT）, improve the determination quality of outpatient and emergency departments, and provide clinical accurate report. Methods The College of American Pathologists （CAP） PT reports were evaluated, and the unpassed items were analyzed and improved into the quality management plan. Results The determination numbers of items in PT and unpassed rates from 2007 to 2011 were2 440, 2.6%; 2 593, 1. 1%; 2 355, 0.6%; 1 894, 0.5%; and 1 799, 0.4%. The differences of unpassed rates from 2007 to 2011 had statistical significance （ P 〈 0. 05 ）. The main factors for unpass were methodological, technical and clerical errors. Conclusions During the last 5 years, the PT unpassed rates decrease significantly. CAP accreditation is beneficial for the continuous quality improvement.