Root Cause Analysis in The Medical Lab: An Example In my line of work, I get to encounter a variety of conflicts with special respect to patient care. The most popular critical analysis tool that can be utilized is the Root Cause Analysis. This toolkit really ensures us as healthcare providers to be extremely mindful of even the most basic process, as any mistake can be detrimental to the patients, the hospital and the future career of the providers. One of the infrequent problems that I tend to experience in my work area is the mislabeling of patient specimen, which can result in an immediate sentinel event. As with all sentinel event a Root Cause Analysis (RCA) is automatically activated when problems like this occurs. In this …show more content…
By now I could rule out any form of equipment malfunction, as all quality control, calibrations and daily maintenance were successfully completed and passed. Any form of questions will be geared towards human, the lab policy and procedures with regards to testing and labelling. The manager from the specified nursing department along with the lab managers will revisit the policy on labelling, as how to, when, where, with what labels and by whom. What happened during this particular labelling process? How busy was the surroundings or if a temporary hospital label was placed onto the specimen tube until it reaches the lab for a permanent relabeling? Did the label bear the initial of the employee? Even if it does bear the initial, which happens in all cases, the managers need to know why the specimen was mislabeled. Does the person have a track record of mistakes? What other patients has she or he label since the beginning of the shift? According to Mind Tools Ltd. (1996-2016), a chart can be created to detailed the scenario of the situation. What is the order of the collection process practices among workers? Does it totally embody that of the procedure manual? If the mislabeling began in the nursing department or in the lab, needs to be clearly identified and proceed with identifying the root …show more content…
This equipment is also provided to the nurses complements of the lab but they seldom use this citing lack of training and the slow process. Resulting from this management meeting, both the lab director and the nursing director agreed that the mandatory use of the patient identification machine is required and will be enforced. A memorandum will be issued by the nursing director to her staff outlining the necessary changes and consequences for not following the protocol. Labelling will be performed only by the personnel that draws the specimen. If any tests need to be added onto the existing specimen that are already in the lab, two techs will be required to match the appropriate label and co-sign the process indicating on the sample