Sign In
CPSI Share                                             
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Topic: Specimen/Laboratory
Publication Type: Sentinel Event Alert
Single or Multiple Incident: single
Date: 6/1/2007 12:00:00 AM
Country: United States of America
Organization: Pennsylvania Patient Safety Authority (USA)

"Patient safety incidents can occur in multiple locations within a healthcare facility. One near miss incident involved an experienced laboratory technician who interpreted a control slide in the laboratory as a patient slide. The information was reported and the patient was prepared for a surgical procedure due the information. The laboratory technician recognized the error and contacted the surgical team. Fortunately, the correct result was reported before the surgical procedure was started. The facility's investigation revealed that both the control slides and patient slides were identical in design- plain, clear, non-distinct glass. At the time no procedure was in place that would differentiate between control slides and patient slides. As a result of the potential serious patient safety incident the facility set forth actions to reduce risk and prevent any future confusion. "



Going beyond the simple fix