Monday, August 20, 2007

The Human Element and Screw-Ups

I have a little lab in my office, as you may know. Nothing fancy, just semen analysis and urine analysis, but to do these tests, I need a CLIA ID, and I must run my lab with an eye on quality control. To that effect, I have taken great pains to prevent specimen mix-ups. Here is how I did it:

  • Pre-label specimen cup with patients name and DOB.
  • Staff gives appropriate patient the cup with their name on it.
  • Patients produces appropriate body fluid into cup, and leaves cup in bathroom, etc.

Here is why I recently changed:

  • Staff gave cup labeled John Smith to patient named Mary Washington
  • And vice-versa
  • The mistake was caught in time

Here is how I do it now:

  • Pre-labeled cup as before
  • Staff gives patient cup
  • Patient signs attestation sheet that verifies that name on cup is their own
  • Attestation sheets are saved

Humans are wonderful. I love them. But you must admit it, we, as a species, can and will find any and all ways to screw-up. Scary stuff. Better re-think your processes and close up the holes.

Thanks for listening,

The IU.