Abstract
Most of the work processes in a pathology laboratory are performed manually by multiple medical technologists; therefore, human error is more likely to occur in examinations performed in pathology laboratories than medical examinations performed in other departments. Thus, our hospital uses “Laboratory Note” as a part of the medical safety management. The information management from this note is operated within the pathological examination system of the Laboratory Information System. So far, reports have emphasized on the importance of incident report and quality management systems in pathological laboratories; however, there have been no research reports on medical safety management using the Laboratory Note.
This study included 527 cases reported in the Laboratory Note from September 2015 to August 2019. These cases were stratified into 30 categories, and a series of examinations were classified into three categories: pre-examination, examination, and post-examination, and the number of reports by year was also tabulated. The most frequently reported category was pathology number management in 53 cases (10.1%). In addition, the number of categories reported during the examination process was the highest at 20 types and 287 cases, followed by 18 types and 166 cases before the examination. Moreover, there was a negative correlation with the number of annual changes and the number of reports.
Records are indispensable for medical safety management in pathological laboratories. The members of the pathology laboratory recorded and shared the various risks and challenges they have experienced during their work in the Laboratory Note. Occasionally, unexpected events can occur daily. The aim of this study was to establish corrective measures to prevent errors from developing into major setbacks.
This paper suggests the importance of risk management in pathological and cytological examinations by risk-assessing the events recorded in this study.
