Medical Errors: Pre-Analytical Issue in Patient Safety

Kratak sadr`aj: U poslednjih nekoliko decenija zna~ajno je smanjena stopa analiti~kih gre{aka u klini~kim labora to rijama, dok sve ve}i broj dokaza pokazuje da su prei post-analiti~ki koraci u ukupnom postupku testiranja (TTP) podlo`niji gre{kama od analiti~ke faze. Preciznije, ve}ina gre{aka je otkrivena u pre-preanaliti~kim koracima, izvan laboratorije i van njene kontrole. Me|utim, u okviru pristu pa pru`anju zdravstvenih usluga orijentisanog na pacijenta postoji potreba da se istra`i, u ukupnom postupku testi ra nja, svaki potencijalni nedostatak koji mo`e negativno uticati na pacijenta, nezavisno od toga o kom se koraku radi i da li gre{ka zavisi od laboratorije (npr. kali bracija ili gre{ka u testiranju) ili nelaboratorijskog osoblja (npr. ne odgovaraju}i zahtev za test, gre{ka u identifikaciji pacijenta i/ili uzimanju krvi). U pre-analiti~koj fazi u~estalost po gre{ne identifikacije pacijenta/uzorka i prisustvo potencijal nih razloga za odbijanje uzorka (hemoliza, zgru{avanje, ne dovoljna zapremina itd.) predstavljaju va`an rizik za bez bed nost pacijenta. Spre~avanje gre{aka u pre-anali ti ~kim koracima zahteva kako tehnolo{ki razvoj (narukvice, barko dovi, pre-analiti~ke radne stanice) tako i blisku sa radnju u klini~kom svetu, radi postizanja efikasnog timskog rada. Naj va`nija lekcija koju smo nau~ili je, dakle, da se labo ratorijske gre{ke i radnje {tetne za pacijenta mogu spre~iti preoblikovanjem sistema koji zdravstvenim radni cima u svim koracima ukupnog postupka testiranja ote`a vaju prav ljenje gre{aka.

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