【摘要】 目的利用风险管理对不良事件进行风险评估与管理,从而降低实验室质量风险,提升实验室质量管理水平。方法通过1例NT-proBNP(心钠肽氨基端前体)结果与临床诊断不符的投诉,实验室组织相关专业组骨干进行风险识别与评估,并结合鱼骨图进行原因分析,进一步制定质量控制计划,通过监督进行跟踪验证,记录整个风险管理过程形成报告,最终实现提升质量管理水平的目的。结果经过风险评估,该NT-proBNP结果不符合临床诊断的投诉为不良事件,为不可接受风险,进一步进行原因分析发现,在检验分析的前、中、后均存在风险,实验室针对性制定纠正措施,使风险消失或降低。结论实验室利用风险评估的方法对存在的质量风险进行识别与评估,有利于风险产生原因的查找,并针对性制定纠正措施,从而真正降低风险,提高质量水平。更多还原

【Abstract】 Objective To decrease the quality risk and to improve the quality control of medical laboratory through risk management on adverse events.Methods According to a case of complaint on the result of NT-proBNP(NT-proB-type natriuretic peptide)inconsistent with the patient’s clinical symptoms,we identified and accessed the risk of the adverse events,and analyzed it by using fishbone diagram.We then designed and performed the quality control pipeline.Furthermore,we tracked and verified the effectiveness of these measures and all the control measures which were recorded.Results ased on risk identified and assessed,the complaint was classified as an adverse event with an unacceptable risk.Further causal investigation indicated certain amount of risks existed in all stages of analysis.It is required to decrease and dismiss the risk by the appropriate action plan.Conclusion By assessing and identifying the quality risk in medical laboratory,it can facilitate the identification of the reason of the risk and further to design and implement the control process,in order to decrease the risk and improve the quality.更多还原