Incident Management: Developing a Plan - COLA

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Incident Management Investigation Report Form Appendix A - COLA LabGuide 71 Report of Investigation Findings: What did the true cause investigation and analysis find? a. What factors are involved in the event? (e.g., Human, Equipment, Controllable Environment, Uncontrollable External factors) b. What systems or processes underlie these factors? (e.g., Human resource issues, Information Management issues, Emergency & Failure-Mode responses, Leadership issues, Uncontrollable factors) Patient Outcomes: Correction Action to be Taken as a Result of Investigation Findings: What will you do to prevent reoccurrence of the incident? Action Plan True Cause / Opportunity for Improvement Action to Reduce Reoccurrence Person(s) Responsible for Implementation Date of Implementation Result Expected Person Responsible for Reviewing the Findings: Date of Review of Report: Person Responsible for Communicating the Findings to Staff: Date of Communication Report: Follow-Up Actions to be Taken: (Check all appropriate actions) No action required Development of new policy / Cease patient testing procedure Communication of findings to staff Revision of policy / procedure Refer patient testing Staff training and in-service Staff competency assessment Resume patient testing Corrective action monitoring Corrective action follow-up and review by (date): Findings inconclusive -- monitor process. Review by (date): Information is incomplete; follow-up to be completed by (date): Notes/Comments: Report Submitted by: Report Approved by: Date: Date: Attach additional information if necessary, including all applicable laboratory reports. - Page 2 of 2 © COLA--5/03. COLA LabGuide® is a registered trademark of COLA. THE INFORMATION IN THIS LABG UIDE IS BASED ON SOUND LABORATORY PRACTICE--IT DOES NOT NECESSARILY REFLECT COLA ACCREDITATION CRITERIA.
Incident Management Investigation Report Form Appendix A - COLA LabGuide 71 Facility Information: (Complete all information) Facility Name State Circle Testing, Inc Laboratory Director Dr. John Smith Address State Circle Phone 555-555-1212 Fax Number 555-555-1213 City, State, ZIP Statesville, XX, 99999 Person Reporting Event: Sue Tech Date: 3/25/03 Reporting Information: (Complete all information) Date of Incident Number of Persons Affected Incident: 3/10/03 to 3/13/03 Patient(s): 10 Time: unknown Staff: Other(s): Event Type: (Check all appropriate event types) Death related to treatment Injury due to treatment Mis-identification of specimen Death related to medication error based on lab result Failure in safety procedure Hemolytic blood transfusion reaction Mis-identification of report [ Procedures involving the wrong patient Misdiagnosis based on laboratory report Instruments or materials retained in the patient following a procedure Physical attack or abduction Instrument & methodology failures Procedures involving the wrong body part Recurring complaints about phlebotomy or specimen collection Other catastrophic event (describe) Patient/Staff Information of Person Affected by Event: (Complete all information) Name: Last See attached list of all Pts First Middle D.O.B: See attached list of all Pts Patient Identification Number: Treatment Date: 3/10 - 13/03 Person Responsible for Investigation of Event: Current status: (circle) Date of Investigation Report: 3/27/03 Regulatory Agency to be Notified of Incident: Date of Notification: Ordering Physician to be Notified of Incident: Discharged Hospitalized Deceased Unknown Fred Jones, Hematology Supervisor and Ellen Jonson Not applicable Date of Notification: 3/28/03 Person to be Notified of Incident: Date of Notification: 3/28/03 Yes, see attached list. Yes, see attached list Brief Summary of Incident: What happened and how was it handled? What area is affected? Ten patient CBC results were performed on 3/10/03 and 3/13/03 by two occasional part-time laboratory testing persons running the Instrument. The CBC results were not written on the appropriate test report and the 10 patient results were released to the ordering physicians. Several patient reports with critical value WBC and Platelet Count results were called to ordering physicians. The critical values on the reports did not match the verbal reports released to the ordering physician. Ordering physicians called Sue Tech on 3/25/03 questioning the paper patient reports. Fred Jones confirmed the error on 3/25/03 upon review of 3/10/03 to 3/13/03 CBC test logs and patient reports. Attach additional information if necessary, including all applicable laboratory reports. - Page 1 of 2 © COLA--5/03. COLA LabGuide® is a registered trademark of COLA. THE INFORMATION IN THIS LABG UIDE IS BASED ON SOUND LABORATORY PRACTICE--IT DOES NOT NECESSARILY REFLECT COLA ACCREDITATION CRITERIA.
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Incident Management: Developing a Plan - COLA

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