臨床検査技術科の患者誤認事例の現状と取り組み

Abstract

臨床検査に関連した患者誤認事例は，不必要な治療等の重大な患者不利益につながる可能性がある． 今回，2017 年1 月から12 月までに臨床検査に関連した患者誤認事例のインシデント報告116 件のうち，最も多く発生した病 棟実施済み心電図検査患者ID 入力間違い・未入力事例104 件について分析を行い，患者誤認防止の取り組みを行った． その防止対策として，2017 年度よりインシデントレポートシステムを用いて，病棟実施済み心電図検査患者誤認事例を関連 部署に報告し，注意喚起を行った．また，2018 年度には医療安全推進室と連携して5 月医療安全ニュースによる啓発活動や病 棟心電計マニュアルの見直し，関連部署への心電図操作研修会の開催の取り組みを行った．これらの取り組みにより，2018 年 病棟実施済み心電図検査患者ID 入力間違い・未入力件数が47 件と前年の104 件から減少した． 今後も「Plan：計画」，「Do：実行」，「Check：評価」，「Action：改善」のPDCA サイクルを効果的に運用することで患者 誤認件数の減少を目指し，医療の質向上に取り組みたいと考える．

By mistaking a patient at the time of clinical testing, the patient may suffer serious disadvantages such as unnecessary treatment. From January to December, 2017, 116 incidences of mistaken identification of patients were reported. In order to prevent such mistakes, we analyzed 104 of these incidences which were of the patients who had had electrocardiography(ECG) at the ward (ward-ECG) but whose ID had been mistaken or was not input. Using the incidence report system we have been reporting the incidences of mistaken input of the ward-ECG patient’s ID since 2017, to alert the relevant wards. In 2018, in cooperation with the Medical Safety Promotion Room we started a campaign to prevent the incidence of mistakes in the May issue of the Medical Safety News, revised the ECG manual used at the ward, and had held meetings for ECG operation training at the related wards. By these actions, the incidence of mistaken patient’s ID input of the ward-ECG was reduced to 47 from 104 in the preceding year. We intend to use the Plan-Do-Check-Action (PDCA) cycle effectively to reduce the number of mistaken patients, and to improve the quality of medical treatment.