Blood gas and patient safety: considerations based on experience developed in accordance with the Risk Management perspective
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Marco Rambaldi
Abstract
It is the responsibility of health organizations to guarantee a high level of healthcare by using adequate methodologies and instruments, creating secure conditions for treatment, and preventing adverse events due to human or system errors. It is necessary to introduce Risk Management programs, and in particular to promote Clinical Risk Management, one of the constituent elements of Clinical Governance, to assure the delivery of high-quality performance and services. In the point-of-care testing (POCT) context, using an analysis of our experiences, we discuss the entire analytical process, including acquisition and usage, while focusing on blood gas analyzers. Our experience confirms that within a Clinical Governance framework, it is necessary to apply, even when choosing instruments, a systematic vision that is not limited to analytical validation, but also includes an in-depth analysis of the impact in a specific context. Assessment of the correlated risks, independent of the analytical methodology used, is indispensable in a clinical environment to identify the most suitable approach for such risks. A study of the latent factors can be proactively performed to identify (and stimulate) what the pre-organizational environment (producer companies) can offer in terms of product orientation to effectively reduce correlated risk during use. Among the different options for possible treatment of risk, one involves the transfer of the assumption of risk to third parties (e.g., maintenance and quality controls). Transferring the responsibility for control operations to the operator of the instrument, which follows the quality controls with total autonomy, is equivalent to transferring the correlated risk for the clinician (in the POCT case) to the producer, who becomes the guarantor. In practice this is equivalent to a specific assurance stipulation with zero cost.
Clin Chem Lab Med 2007;45:774–80.
©2007 by Walter de Gruyter Berlin New York
Articles in the same Issue
- Foreword
- Errors in laboratory medicine and patient safety: the road ahead
- How can we make laboratory testing safer?
- “Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory
- Risk management in the preanalytical phase of laboratory testing
- Recommendations for detection and management of unsuitable samples in clinical laboratories
- Effects of analytic variations in creatinine measurements on the classification of renal disease using estimated glomerular filtration rate (eGFR)
- Process and risk analysis to reduce errors in clinical laboratories
- Reduction of multi-dimensional laboratory data to a two-dimensional plot: a novel technique for the identification of laboratory error
- Does external evaluation of laboratories improve patient safety?
- Risk management in laboratory medicine: quality assurance programs and professional competence
- Point-of-care testing, medical error, and patient safety: a 2007 assessment
- Blood gas and patient safety: considerations based on experience developed in accordance with the Risk Management perspective
- The role of in vitro diagnostic companies in reducing laboratory error
- Application of the Six Sigma concept in clinical laboratories: a review
- One hundred years of laboratory testing and patient safety
Articles in the same Issue
- Foreword
- Errors in laboratory medicine and patient safety: the road ahead
- How can we make laboratory testing safer?
- “Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory
- Risk management in the preanalytical phase of laboratory testing
- Recommendations for detection and management of unsuitable samples in clinical laboratories
- Effects of analytic variations in creatinine measurements on the classification of renal disease using estimated glomerular filtration rate (eGFR)
- Process and risk analysis to reduce errors in clinical laboratories
- Reduction of multi-dimensional laboratory data to a two-dimensional plot: a novel technique for the identification of laboratory error
- Does external evaluation of laboratories improve patient safety?
- Risk management in laboratory medicine: quality assurance programs and professional competence
- Point-of-care testing, medical error, and patient safety: a 2007 assessment
- Blood gas and patient safety: considerations based on experience developed in accordance with the Risk Management perspective
- The role of in vitro diagnostic companies in reducing laboratory error
- Application of the Six Sigma concept in clinical laboratories: a review
- One hundred years of laboratory testing and patient safety
