Incident Management: Developing a Plan - COLA

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)
There appears to be two causes to the event.
(1) The testing persons switched the order of the paper test requisitions
(2) There were several CBC test request forms with incomplete or partial patient identifiers (first initials only, no
patient identifier number)
b. What systems or processes underlie these factors? (e.g., Human resource issues, Information Management issues,
Emergency & Failure-Mode responses, Leadership issues, Uncontrollable factors)
(1) It appears that the testing persons were unfamiliar with the CBC report form.
(2) It appears that the policy for completing the CBC test request with the required patient information does not
clearly state the patient identifying information that is required.
Patient Outcomes: Two patients were inappropriately hospitalized based upon the results. Two other patients required repeat visits to
their specialist four days following the release of reports to their physician. All patients were contacted to have repeated testing performed at
our laboratory. No patient deaths occurred due to the error.
Correction Action to be Taken as a Result of Investigation Findings: What will you do to prevent reoccurrence
of the incident?
Recommend Corrective Action:
(1) Verify that all testing personnel understand the CBC report form. Provide an in-service to permanent and part-time staff.
(2) Rewrite and clarify the procedure for completing the CBC test request form. Review the revised policy with staff.
(3) Train staff to review test results at the end of day rather than waiting for review by supervisor at a future date.
Action Plan
True Cause /
Opportunity for
Improvement
Communication of patient
identification on test request
Action to
Reduce
Reoccurrence
Revise policy for
ordering of tests
Person(s)
Responsible for
Implementation
Date of
Implementation
Result Expected
Laboratory Director May 1, 2003 100% compliance with revised
communication policy
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 /
procedure
Cease patient testing
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): 5/15/03
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.