检体采集作业流程病人同意课件

謝文祥

檢驗結果異常的原因分析與臨床因應謝文祥檢驗結果異常的原因分析與臨床因應2013Hospital

NationalPatientSafety

GoalsIdentifypatientcorrectlyImprovestaffcommunicationUsemedicinessafelyPreventinfectionCheckpatientmedicinesIdentifypatientsafetyrisksPreventmistakesinsurgeryTheJointCommissionAccreditationHospital2013Hospital

NationalPatient2013Laboratory

NationalPatientSafetyGoalsIdentifypatientcorrectlyImprovestaffcommunicationPreventinfectionTheJointCommissionAccreditationLaboratory2013Laboratory

NationalPatien年度目標的演進93年五大目標94年六大目標95～96年八大目標1.避免藥物錯誤1.提升用藥安全1.提升用藥安全2.落實院內感染控制2.落實院內感染控制2.落實醫療機構感染控制3.杜絕手術錯誤、病人錯誤及手術程序錯誤3.提升手術正確性3.提升手術正確性4.避免病人辨識錯誤4.提升病人辨識的正確性4.提升病人辨識的正確性5.預防病人跌倒5.預防病人跌倒5.預防病人跌倒6.鼓勵異常事件通報6.鼓勵異常事件通報7.改善交接病人之溝通與安全8.提升民眾參與病人安全TaiwanJointCommissiononHospitalAccreditation

年度目標的演進93年五大目標94年六大目標95～96年八大目2008-2009年度目標的演進1.提升用藥安全2.落實醫療機構感染控制3.提升手術安全4.預防病人跌倒及降低傷害程度5.鼓勵異常事件通報及資料正確性6.提升醫療照護人員間溝通的有效性7.鼓勵病人及其家屬參與病人安全工作8.提升管路安全TaiwanJointCommissiononHospitalAccreditation2008-2009年度目標的演進1.提升用藥安全Taiwan2010-2011年度目標的演進提升用藥安全落實醫療機構感染控制

提升手術安全預防病人跌倒及降低傷害程度鼓勵異常事件通報及資料正確性

提升醫療照護人員間溝通的有效性鼓勵病人及其家屬參與病人安全工作提升管路安全加強醫院火災預防與應變TaiwanJointCommissiononHospitalAccreditation2010-2011年度目標的演進提升用藥安全TaiwanObjectivesIdentifythesignificantpre-analyticalerrorsthatcanoccurduringbloodspecimencollectionandtransport.Explainthevariousmeansofpre-analyticalerrorprevention.Listproactivestepstoreducepotentialpre-analyticalerrorsassociatedwithbloodcollectionandtransport.ObjectivesIdentifythesignifiIntroductionThreephasesoflaboratorytesting:pre-analytical,analytical,post-analyticalPre-analytical:specimencollection,transportandprocessingAnalytical:testingPost-analytical:testingresultstransmission,interpretation,follow-up,retestingIntroductionThreephasesoflPhlebotomyErrorsPhlebotomyisahighlycomplexskillrequiringexpertknowledge,dexterity,andcriticaljudgmentItisestimatedthatonebillionvein-puncturesareperformedannuallyintheU.S.PhlebotomyErrorsmaycauseharmtopatientsorresultinneedle-stickinjurytothePhlebotomistPhlebotomyErrorsPhlebotomyisPre-analyticalerrorsPre-andpost-analyticalerrorsareestimatedtoconstitute90%oferrorsErrorsatanystagesofthecollection,testingandreportingprocesscanpotentiallyleadtoaseriouspatientmisdiagnosisErrorsduringthecollectionprocessarenotinevitableandcanbepreventedwithadiligentapplicationofqualitycontrol,continuingeducationandeffectivecollectionsystemsPre-analyticalerrorsPre-andTypesofcollectionerrorsPatientIdentificationPhlebotomyTechniqueTestCollectionProceduresSpecimenTransportSpecimenProcessingTypesofcollectionerrorsPatiPatientIdentificationErrorsErrorsincorrectlyidentifyingthepatientareindefensibleReasonsforpatientidentificationerrors:ProperpositivepatientidentificationproceduresnotfollowedPatientidentificationfromidentificationbracelet(inpatients)Patientidentificationbyaskingpatienttostateorspelltheirfullname(inpatients/outpatients)Patientidentificationbystafforfamilymemberifpatientunabletoidentifyhim/herselfPatientIdentificationErrorsEPatientIdentificationErrorsSpecimentubesunlabeled:RequisitionorcollectiontubelabelsnotaffixedtotubesRequisitionorcollectiontubelabelsinbagcontainingcollectiontubesRequisitionorcollectiontubelabelsrubber-bandedtotubesCollectiontubelabelsnotaffixedtoalltubesSpecimencollectiontubeslabeledinsufficientlywithatminimumpatient’sfullname,date/timeofcollection,phlebotomist’sinitialsPatientIdentificationErrorsSPatientIdentificationErrorsCollectiontubeslabeledwiththewrongpatientWrongcomputerizedlabelsaffixedtocollectiontubesatbedsideCollectiontubesnotlabeledatthetimeofcollectionCollectiontubesincorrectlylabeledbysomeoneotherthanthephlebotomistwhocollectsthespecimenPatientIdentificationErrorsCPatientComplicationsSomepatientvariablesthataffectbloodspecimensDietFastingExerciseObesityAllergiestoalcoholoriodineusedtocleanvein-puncturesiteUsealternativecleansersuchaschlorhexidinPatientComplicationsSomepatiPhlebotomyTechniqueErrorsPhlebotomytechniqueisimportantEnsurestestresultvalidityMinimizestraumatopatientMinimizespotentialforphlebotomistinjuryReducesrecollectionsVeinselectionessentialforsuccessfulVein-punctureThreeveinsinantecubitalfossainorderofselection(1)mediancubital(2)cephalic(3)basilicPhlebotomyTechniqueErrorsPhlPhlebotomyTechniqueErrorsSiteSelectionAvoidsiteswithIVUsealternativearmordrawbelowIVtoavoidcontamination/dilutionfromIVDocumentarmifIVMastectomy—avoidsiteduetolymphostasisInfectionrisk/alterationinbodyfluidsandbloodanalytesEdematousareas—avoidduetoaccumulationofbodyfluidsPossiblecontamination/dilutionofspecimenPhlebotomyTechniqueErrorsSitPhlebotomyTechniqueErrorsVenousAccessDifficultiesObstructed,hardened,scarredveinsVeinsdifficulttolocateUseofAlternativesitesTopofhand/SideofwristAreastoavoidVeinCollapseUseofappropriateneedlesizeSmallerevacuatedcollectiontubePhlebotomyTechniqueErrorsVenPhlebotomyTechniqueErrorsTourniquetApplicationTourniquettiedtooclosetothevenipuncturesitecancausehematomaVeinsmaynotbecomeprominentiftourniquetistiedtoohigh(morethan3to4inchesabovevenipuncturesite)Tourniquetleftonlongerthanoneminutecanresultinhemoconcentration,affectingsometestresultsTourniquetshouldbereleasedassoonasneedleisinthelumenoftheveinandbloodflowestablishedPhlebotomyTechniqueErrorsTouPhlebotomyTechniqueErrorsCleansingofvenipuncturesiteThoroughcleaningwithalcoholAllowalcoholtodrycompletelytoavoidstingingsensationuponneedleentryandhemolysisofsampleSamplessuchasbloodculturesshouldbecollectedusingiodinetocleansesitetoensuresterilityofsampleRecollectionrateforbloodculturesrangesduetocontaminationisashighas50%inhospitalswithincreasedcosts,patientovertreatmentPhlebotomyTechniqueErrorsClePhlebotomyTechniqueErrorsCorrectcollectionsystemEvacuatedtubesystem(Vacutainer)forlargeveinsinantecubitalfossaSyringeforsmall,fragileveinsorveinsoutsideantecubitalfossaVenousaccessNeedleentryshouldbeat15to30degreesdependingondepthofveinNeedleentryshouldbeinsamedirectionasvein,centeredoverveinAnchorveintopreventmovementduringneedleentryandtoreducepaintopatientPhlebotomyTechniqueErrorsCorTestCollectionErrorsOrderofDrawOrderofdrawaffectsthequalityofthesampleandcanleadtoerroneoustestresultsduetocontaminationwiththeadditivefromthepreviousbloodcollectiontubeHemolysisBloodcollectedinsufficienttoamountofadditiveintubeTraumaticvenipunctureBloodcollectedfromareawithhematomaVigorousshakingoftubesaftercollectionMilkingthesitewhencollectingcapillarysamplesandbloodcollectedusingasmalldiameterneedle

TestCollectionErrorsOrderofTestCollectionErrorsTimingoffCollectionTimedDrawsTherapeuticDrugMonitoringPeakandtroughcollectiontimesBasalStateCollectionsFastingrequirements—nofoodorliquidexceptwaterSpecimensaffectedbytimeofday,forexample,cortisolTestCollectionErrorsTimingoTestCollectionErrorsImpropercollectiontubedrawnfortestorderedCollectiontubenotcompletelyfilledExample—lightbluetoptubeforCoagulationStudies.IncompletefillingresultsinspecimendilutionanderroneousProthrombinandaPTTtestresultsTestCollectionErrorsImproperTestCollectionErrorsCapillaryCollections—fingerstickorheelstickAppropriatesiteHeelstick—sidesofthebottomsurfaceoftheheelFingerstick—thirdorfourthfingers,perpendiculartofingerprintlinesonfleshypadsonfingersurfaceWarming—WarmbeforecollectiontoincreasecapillarybloodflownearskinsurfaceCleaning—cleansesitewithalcoholandallowtoairdryTestCollectionErrorsCapillarCapillaryCollectionsMassagingsitetoincreasebloodflowMilkingsitecancausehemolysisortissuefluidcontaminationFingersticks—rollfingerstowardfingertipat1stfingerjointseveraltimesHeelsticks—gentlysqueezeinfant’sheelbeforeperformingpuncture.PerformpuncturewhilefirmlysqueezingfingerorheelWipeawayfirsttwodropsofbloodEnsurethatfullblooddropwellsupeachtimeCapillaryCollectionsMassagingCapillaryCollectionsAvoidtouchingcapillarycollectiontubeormicrocollectiontubetoskinorscrapingskinsurfaceContaminatespuncturesiteBloodmaybecomehemolyzedMixingmicrocollectiontubeswithadditivefrequentlytoavoidmicroclotsCollectingtubeswithadditivesfirstProtectingtubesforbilirubinfromlightCapillaryCollectionsAvoidtouGoodSampleHandlingDrawthecorrectvolumeMix:It’sessentialAllowtimetoclotSpinunderthecorrectconditionsAspirate,Don’tpourRefertotheproductinsertorpackagelabelingsuppliedbythemanufactureofanybloodcollectionproductforcompleterecommendationsonsamplecollectionandprocessingReference:CLSI(H3-A6)2008/CLSI(H18-A3)2004

GoodSampleHandlingDrawthecBloodSpecimenTransportErrorsTransportofbloodspecimensinthepropermanneraftercollectionensuresthequalityofthesampleTimingSomespecimensmustbetransportedimmediatelyaftercollection,forexampleArterialBloodGases.SpecimensforserumorplasmachemistrytestingshouldbecentrifugedandseparatedwithintwohoursBloodSpecimenTransportErrorTransportErrorsTemperatureSpecimensmustbetransportedattheappropriatetemperaturefortherequiredtestOnice—ABGs,AmmoniaWarmed--98.6degrees(37C),cryoglobulinsAvoidtemperatureextremesiftransportedfromviavehiclefromothercollectionsiteTransportContainerSomesamplesneedtobeprotectedfromlight,forexample,bilirubinTransportinleak-proofplasticbagsinlockablerigidcontainersTransportErrorsTemperatureErrorPreventionPhlebotomyEducationPhlebotomistsshouldhavecompletedastandardacademiccourseinphlebotomyandundergothoroughon-the-jobtrainingunderthesupervisionofaseniorphlebotomistContinuingEducationPhlebotomistsshouldparticipateinregulareducationalcompetencyassessments(writtenandobservational)ProfessionalLicensurePhlebotomyStaffingAdequatestaffingtomaintaincollectionstandardsTechnologyUseofbarcodescannersforpatientidentificationErrorPreventionPhlebotomyEduQuestionsandDiscussionHowarepre-analyticalerrorspreventedinyourlaboratory?Whattechnologydoyouusetopreventhumanerror?Whatsystemsdoesyourhospitalusetopreventerrorsbynon-laboratorystaffcollectingblood?Whatpro-activeimprovementswouldreducethenumberofpre-analyticalerrors?QuestionsandDiscussionHowar檢體採集作業流程病人同意：醫療或研究需求？病人辨識：原則、方法(時機、頻率)病人保護：隱私、安全(消毒、暈針)衛教說明：口頭、單張、媒體、手冊正確採集：檢體量、檢體種類保存傳送：保存劑(抗凝劑)、溫度、包裝檢體訂定允收原則的必要與省思？檢體重採的限制與省思？TaiwanHospitalAssociation2007檢體採集作業流程病人同意：醫療或研究需求？TaiwanHo檢驗前流程(程序)Pre-examinationProcedure(Process)檢驗前流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)SamplingIdentificationBarcodelabelingSingletube(CloseContainerSystem)InsideAliquot(Auto-Centrifugation)TLA(Auto-Transportation)EfficiencyandEffectiveness

案例一病人晚上掛急診，白血球(WBC)報告為630，第二天上午主治醫師請CCU再追蹤一次WBC，病人的報告為17530，因兩次報告差異大，所以CCU專科護理師打電話至檢驗科，請醫檢師重驗前一天於急診所驗的WBC，但醫檢師表示因當時所抽的血量不夠，無法再重驗，所以也無法確認前一天急診WBC報告是否正確?案例一病人晚上掛急診，白血球(WBC)報告為630，第二天抽錯病人編號錯誤(貼錯標籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質報告填錯抽錯病人案例二病人因頭部鈍傷，頭暈至急診就醫，醫師診視後，給予打上點滴，抽CBC、生化檢驗，隨後醫檢師通報危險值，告知醫師血紅素3.8，詢問病人表示平時無貧血症狀且還有在捐血，故依照醫矚再抽第二次CBC，血紅素:13.3?案例二病人因頭部鈍傷，頭暈至急診就醫，醫師診視後，給予打上點抽錯病人編號錯誤(貼錯標籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質報告填錯抽錯病人檢驗流程(程序)ExaminationProcedure(Process)檢驗流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)CalibrationInternalQualityAssessment(QC)ExternalQualityAssessment(PT)EfficiencyandEffectiveness

案例三於03：53抽血aPTTdata180.4sec，當時血液室電話告知通報危險值，護理人員立即告知主治醫師及住院醫師，主治醫師立即囑輸注FFP2UIVDst、vitK11ampIVDst，並請住院醫師追蹤aPTTprolong原因，住院醫師詳細評估後，囑recheckaPTT、PTdata，表示第二次追蹤若真的是有延長情形，預備檢驗其他凝血功能。於05：39再驗結果aPTT34.7sec、PT14.4sec（抽血時尚未執行FFP及K1醫囑），電話詢問血液室人員為何兩次檢驗數值差距大?檢驗室人員才表示第一次檢驗數值是因為機台故障（未主動告知SICU），故第二次檢驗數值才以人工計數執行。[如何發現機台故障，補救程序為何?]案例三於03：53抽血aPTTdata180.4se抽錯病人編號錯誤(貼錯標籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質報告填錯抽錯病人案例四病人3/28由ER入,因H/D3/30轉床,病人CPK、CK-MB、Troponin-I一直偏高所以