病理报告错误分析及质量控制的探讨

Error Analysis of Pathology Report And Discussion of Quality Control

病理报告是疾病诊断的重要医学文书,能够帮助临床医师确定诊断、明确分型,为临床诊疗提供证据支持,是保障医疗质量与患者安全的重要依据,同时也是病案的重要组成部分。本文通过回顾性分析某院已上报的病理报告错误相关不良事件,确定了目前某院病理报告错误的主要原因是在病理申请、送检、接收、处理以及报告发布等各环节中未严格执行医疗规章制度。由此,为提高病理报告质量和病案质量,医院和科室一方面应建立完善的制度体系,并通过培训保障制度的有效落实;另一方面应健全质量控制体系,加强对运行质控和终末质控的管理,并对关键环节进行重点警示,形成关键环节重点警示的工作形式。

Pathological report is an important medical document for disease diagnosis, which can help clinicians to determine diagnosis, clear classification and provide evidence support for clinical diagnosis and treatment. It is an important basis for ensuring medical quality and patient safety, as well as an important part of medical record. Based on the retrospective analysis of the adverse events related to pathological report errors reported by a hospital, this paper determined that the main reason for the current pathological report errors in a hospital is that the medical rules and regulations were not strictly implemented in the process of pathological application, submission, receiving,handling and report release. Therefore, in order to improve the quality of pathological reports and the quality of medical records, hospitals and departments should establish a sound system on the one hand and effectively implement the training guarantee system;on the other hand, the quality control system should be improved to strengthen the quality control and terminal quality control management, and key warnings on key links, forming a key form of key warning work.