应用PDCA降低检验科危急值漏报率

Reduce the Under-Reporting Rate of Critical Value in Clinical Laboratory by Using PDCA

以医院三甲复评为契机,引入PDCA循环,对检验科危急值漏报率高的问题进行改进。针对危急值项目设置过多,网络报告系统不完善,门诊危急值管理缺陷,主管部门监管力度不足,不熟悉报告处理流程等原因,从调整危急值项目及范围,开发网络直报软件,完善门诊危急值报告制度及流程,加大监管力度,加强员工培训等方面改进。通过改进,检验科危急值平均每月漏报率从1.04%下降为0,实现了危急值100%上报;检验科危急值平均确认时间从17.9分钟缩短到6.2分钟,为危重患者临床抢救争取了更多时间。

With the opportunity of the tertiary hospital review, the PDCA cycle was introduced to improve the problem of the high under-reporting rate of critical value in clinical laboratory. The causes included setting up too many critical value items, incomplete network reporting system, critical value management flaws in outpatients department, inadequate supervision by competent authorities, unfamiliarity with the report processing flow, etc. Improvement was made from aspects of adjusting critical value items and scope, developing online reporting software, and improving outpatient critical value reporting system and processes, intensifying supervision, and strengthening employee training. Through improving, the average monthly under-report rate of critical value in clinical laboratory dropped from 1.04% to 0, achieving 100% report of critical value. The average confirmation time of critical value was shortened from 17.9 minutes to 6.2 minutes, which strived for more time for clinical rescue of critically ill patients.