目的:对已发表的与丢失,贴错标签,以及在分析前阶段对手术和临床病理标本的处理不当。
方法:作者使用系统评价和荟萃分析指南的首选报告项目来搜索PubMed,MEDLINE,WebofScience,和Scopus从1990年1月1日至2023年5月1日发表的相关文章。
结果:作者筛选了1313篇文章,确定了44篇同行评审,在1990年至2021年之间发表的英文文章,以纳入最终的系统审查。大多数文章(n=36)报道了来自美国机构的结果。文章主要集中在一般临床和普通外科病理学。对文章的分析表明,文章报道了一系列方法论方法,包括事件报告,实施分析,案例研究,和评注建议。大多数文章集中在错误标记的错误(61.3%)和丢失或丢失的标本(18.2%),而几篇文章组合样本误差(20.5%)。一些实施研究(22.7%)报告使用多种干预措施来减少错误。实施工作报告病理错误减少了70%至100%。
结论:这篇综述突出了对该主题的有限研究,平均每年有两篇文章讨论丢失,贴错标签,或者标本处理不当。干预研究针对联合委员会实验室实践的患者安全目标。需要对非西方国家的错误事件和报告进行更多的研究,以获得对该主题的更全球视野。
OBJECTIVE: To perform a systematic
review of published academic literature related to lost, mislabeled, and mishandled surgical and clinical pathology specimens during the preanalytical stage.
METHODS: The authors used Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to search PubMed, MEDLINE, Web of Science, and Scopus for relevant articles published from January 1, 1990, to May 1, 2023.
RESULTS: The authors screened 1313 articles and identified 44 peer-reviewed, English-language articles published between 1990 and 2021 for inclusion in the final systematic
review. Most articles (n = 36) reported results from US-based facilities. Articles primarily focused on general clinical and general surgical pathology. Analysis of the articles revealed that articles reported a range of methodological approaches, including incident reports, implementation analyses, case studies, and commentary recommendations. Most articles focused on mislabeling errors (61.3%) and missing or lost specimens (18.2%), while several articles combined specimen errors (20.5%). Several implementation studies (22.7%) reported using multiple interventions to mitigate errors. Implementation efforts reported between 70% and 100% reduction in pathology errors.
CONCLUSIONS: The
review highlights the limited research on the topic, with an average of 2 articles per year discussing lost, mislabeled, or mishandled specimens. Intervention studies addressed The Joint Commission\'s patient safety goals for laboratory practice. More research is needed about error incidents and reporting in non-Western countries to gain a more global perspective on the topic.