Root Cause Analysis of Patient Samples Rejected by Laboratories: 21-Step Application Example

Yıl 2023, Cilt: 13 Sayı: 3, 359 - 367, 21.09.2023

Büşra Arslan , Dilek Şahin

https://doi.org/10.33631/sabd.1188718

Öz

Aim: Root cause analysis is widely used in healthcare services to analyze the causes of near misses and adverse events with a systematic approach. This study, it is aimed to determine the root causes of rejected samples, define corrective/preventive actions, and create an action plan that will help the implementation of the suggested remedial actions and evaluate their effectiveness.
Material and Methods: For the 21-step methodology, observation, interview, document and record review techniques were applied. The steps of the process were visualized with the flowchart technique and the reasons for rejected samples were analyzed with team members. The identified causes were visualized with the Fishbone Diagram technique, and the risk reduction strategies and improvement actions for rejected samples were determined by the Failure Mode Effect Analysis (FMEA) method. The Action Hierarchy tool was used to evaluate the power of improvement actions.
Results: The root causes of rejected samples were identified as inadequate orientation and training practices, lack of applicability of policies and procedures, lack of monitoring and evaluation, inefficient process flow and lack of equipment. A total of 11 improvement actions were determined and planned for these root causes. It was predicted that there will be an approximately 64.5% decrease in risk scores in general with the basic measures presented in the performed FMEA.
Conclusion: Overall, it was found that the 21-step methodology is suitable for determining root causes by offering detailed guidance.

Anahtar Kelimeler

Root cause analysis, rejected samples, 21-step methodology

Laboratuvarlar Tarafından Reddedilen Hasta Numunelerinin Kök Neden Analizi: 21 Adım Uygulaması Örneği

Öz

Amaç: Kök neden analizi, sağlık hizmetlerinde ramak kala ve istenmeyen olayların nedenlerini, sistematik bir yaklaşımla analiz etmek için yaygın olarak kullanılmaktadır. Bu çalışmada, reddedilen numunelerin kök nedenlerinin belirlemesi, düzeltici/önleyici eylemlerin tanımlaması ve önerilen iyileştirme eylemlerinin uygulanmasına ve etkililiğinin değerlendirilmesine yardımcı olacak bir eylem planının oluşturulması amaçlanmıştır.
Gereç ve Yöntemler: 21 adım uygulaması yönteminde gözlem, görüşme, doküman ve kayıt inceleme teknikleri uygulanmıştır. Akış Şeması tekniği ile süreç adımları görselleştirilmiş ve reddedilen numunelerin nedenleri ekip üyeleri ile analiz edilmiştir. Tespit edilen nedenler, Balık Kılçığı Diyagramı tekniği ile görselleştirilmiş ve reddedilen numuneler için risk azaltma stratejileri ve iyileştirme eylemleri Hata Türleri ve Etkileri Analizi yöntemi ile belirlenmiştir. İyileştirme eylemlerinin gücünü değerlendirmek için Eylem Hiyerarşisi aracı kullanılmıştır.
Bulgular: Reddedilen numunelerin kök nedenleri; oryantasyon ve eğitim uygulamaları yetersizliği, politika ve prosedürlerin uygulanabilirliği, izleme ve değerlendirme eksikliği, verimsiz süreç akışı ve ekipman eksikliği olarak belirlenmiştir. Bu kök nedenlere yönelik toplam 11 iyileştirme eylemi belirlenmiş ve planlanmıştır. Gerçekleştirilen Hata türleri ve Etkileri Analizinde sunulan temel önlemlerle genel olarak risk puanlarında yaklaşık %64,5’lik azalış olacağı öngörülmüştür.
Sonuç: Genel olarak 21 adım yönteminin ayrıntılı rehberlik sunarak kök nedenleri belirlemede uygun olduğu bulunmuştur.

Anahtar Kelimeler

kök neden analizi, reddedilen numuneler, 21 adım yöntemi

Kaynakça

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