Analysis of Adverse Events Caused by Sample Collection Errors

1. Concept:

Sample collection errors refer to the errors in collecting a small part of human blood, body fluids (pleural effusion, ascites), excreta (urine, feces), secretions (sputum, nasal secretions), vomit or tissues.

2. Classification:

Wrong patient information, wrong container and wrong specimen type.

Third, risk factors:

There is poor communication between doctors and nurses, and patients have not mastered the precautions for collecting specimens.

the collector failed the check, or the specimen was put on the wrong side, or the specimen type was wrong, or the amount of specimens collected was wrong.

the collector violates the operating rules during the operation, such as violating the aseptic principle.

The quality problem of the specimen box.

The specimen is not kept properly, and the specimen is not sent for inspection in time!

4. Harm:

The specimen test results are wrong, which is easy to be misdiagnosed, resulting in mistakes in disease treatment.

when the sample collection is unqualified, collecting samples for many times will bring more pain to patients.

increase the workload and psychological pressure of medical staff.

The quality problem of specimens will also affect the quality and service life of inspection instruments.

it is easy to cause disputes between doctors and patients.

V. Precautionary measures

Correctly review the doctor's advice for patient specimen collection, and correctly use the specimen collection system to check the information of patient specimen collection.

select a suitable container according to the regulations of specimen collection.

before specimen collection, ask the patient to make preparations before specimen collection, and inform relevant precautions.

check whether the patient information is correct again when collecting samples.

according to the corresponding operating procedures and specifications.

after collection, check again whether the specimen conforms to the patient information and specimen type.

specimens should be submitted for inspection in time and safely within the specified time.

Take occupational protection when collecting specimens.

VI. Emergency Plan

When the specimen collection error is found, if the specimen is not sent to the clinical laboratory, find out the specimen in time; If it has been sent to the clinical laboratory, call the clinical laboratory and suspend the inspection.

report to the head nurse immediately. The competent physician shall determine whether the specimen should be supplemented as an inspection item according to the actual situation. If it needs to be supplemented, the physician shall strictly carry out three inspections and seven pairs after giving the doctor's orders, and then keep the specimen for inspection again; If there is no need to make up, destroy the specimen and explain it to the patient to get the patient's understanding.

fill in the report of nursing adverse events and submit it to the nursing department

to analyze the causes of sample collection errors.

case analysis

patient, Wang, female, 74 years old.

Due to acute upper gastrointestinal bleeding, hemorrhagic shock and unconsciousness, 12 patients were sent to emergency treatment. During the rescue, there was intermittent vomiting of about 2ml of blood, and 6ml of bloody stomach contents were drained by gastrointestinal decompression. According to the condition, red blood cell suspension was infused, and blood routine and blood type were checked according to the doctor's advice.

Before rescuing the second patient, another patient with hypoglycemia shock, Li, was admitted to the intensive care unit, and the routine blood samples were not sent for inspection in time.

A nursing student took the wrong specimen in a hurry, and sent the specimen of patient Li with the name of patient Wang for inspection. Because the inspection result was inconsistent with the diagnosis of the laboratory sheet, the inspector raised doubts and called the nurse. After investigation, it was found that the wrong specimen was sent, and the nurse drew blood from patient Wang again for inspection, thus avoiding a medical accident.

This case is a direct nursing risk, which is caused by the behavior of nurses. Although there are no serious consequences after being questioned by the inspectors, it also brings pain to the patients, and there are serious security risks at the same time.

Cause analysis

The practice nursing students did not strictly implement the check-up system, and the concept of check-up was not deeply impressed in their minds, so they sent away the samples without finding out the patient's name, diagnosis and test items.

exposed the disadvantages in the process of teaching. Interns operate independently from the teacher and fail to teach? Let go and not look?

In the rescue environment, the patient's name should be indicated before venous blood collection, and it should be checked again when it is submitted for inspection.