CAP Pro Course - Laboratory Management - Investigating Occurrences

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Author: Lynne Brodeur, MA, MLS(ASCP)CM
Reviewer: Julie Ann West, PhD, MLS(ASCP)CM, SM(ASCP)CM

Continuing Education Credits

Objectives

  • Define "occurrence" and identify the role of occurrence investigation in the Quality Management System (QMS).
  • Explain how to build an occurrence investigation process that encourages a culture of employee engagement.
  • Identify the primary elements needed for investigating occurrences and discuss their functions.

Course Outline

  • Define "occurrence" and identify the role of occurrence investigation in the quality management system (QMS).
      • Overview of Occurrence Investigation
      • The Role of Occurrence Investigation in the Quality Management System (QMS)
      • Quality Improvement Philosophies and Tools
      • Which of the following would not require follow-up in a quality management system (QMS)?
      • A new supervisor takes over in the chemistry laboratory. In her previous laboratory, staff members were required to change gloves every 30 minutes reg...
      • Mary is a certified nursing assistant (CNA) on the pediatric floor of her local hospital. She witnesses a parent complaining about the way a nurse gav...
      • Which of the following steps is included in an occurrence investigation?
      • A nurse in the Intensive Care Unit has discovered that a phlebotomist left the guard rail down on a patient's bed after she finished drawing morning s...
  • Explain how to build an occurrence investigation process that encourages a culture of employee engagement.
      • "Just Culture"
      • Algorithmic Approach to Determining Cause of Occurrence, Response, and Appropriate Intervention
      • Breaking Down Silos: Perspectives and Collaboration
      • John is a specimen processing technician at a local hospital. He has been an employee for 26 years and has been an employee of the month several times...
      • A medical laboratory scientist (MLS) is summoned to the ICU to collect a stat blood gas sample on a patient. The MLS checks the patient's armband and ...
      • A medical laboratory scientist (MLS) is summoned to the ICU to collect a stat blood gas sample on a patient. The MLS checks the patient's armband and ...
      • A medical laboratory scientist (MLS) is summoned to the ICU to collect a STAT blood gas sample on a patient. The MLS checks the patient's armband and ...
  • Identify the primary elements needed for investigating occurrences and discuss their functions.
      • Primary Elements in Occurrence Investigation Process
      • Element #1: Detection and Reporting
      • Element #1: Detection and Reporting, continued
      • Element #2: Immediate Error Response and Investigation
      • Element #3: Data Review and Analysis (Tracking and Trending)
      • Pareto Chart
      • Root Cause Analysis (RCA)
      • Root Cause Analysis: "5 Whys" Technique
      • Root Cause Analysis: Cause-and-Effect (Fishbone) Diagram
      • Root Cause Analysis: Flowchart of Work Process
      • Element #4: Process Improvement and Recurrence Prevention
      • Interventions for Reducing Errors
      • Carol is the chemistry supervisor in a large urban hospital. She noticed repeated quality control (QC) failures recorded on one of the main chemistry ...
      • A 10-year-old girl is brought into the ER complaining of a sore throat, malaise, fever, and a general lack of appetite. The ER physician orders a comp...
      • Imagine that you've just stepped into a new role as head of the phlebotomy department. You've inherited a number of problems that need your attention....
      • A 10-year-old girl is brought into the ER complaining of a sore throat, malaise, fever, and a general lack of appetite. The ER physician orders a comp...
      • A visiting nurse association has several point-of-care glucose meters. Some of the nurses that have been with the association for a period of time hav...
      • An MLS in the microbiology department stuck herself with a needle used to transfer blood from a blood culture bottle to an agar plate. The incident ha...
      • What is the purpose of a fishbone diagram?
      • It has come to the attention of the senior laboratory management that samples that are ordered stat from the ER are taking longer to process than stat...
      • A patient has had a severe transfusion reaction that resulted in death. According to The Joint Commission (TJC), this is what type of event and what t...
  • References
      • References

Additional Information

Level of Instruction: Intermediate
Intended Audience: This program is designed as an educational and training tool for MLS, MT, and MLT personnel, medical laboratory science students and interns, pathology residents, and practicing pathologists.
Author: Lynne Brodeur, MA, MLS(ASCP)<sup>CM</sup> holds a master of arts degree in teaching. She is currently a full time lecturer at the University of Massachusetts Dartmouth and works per diem in Clinical Chemistry at St. Luke's Hospital in New Bedford, MA.
Reviewer Information: Dr. Julie Ann West is certified by the American Society for Clinical Pathology (ASCP) as a Medical Laboratory Scientist (MLS) and as a Specialist in Microbiology (SM). In addition, Dr. West has earned a PhD in Public Health - Infectious Disease Epidemiology - and is Certified in Public Health (CPH) by the National Board of Public Health Examiners. Dr. West is experienced as a Technical Specialist, Safety Officer, Educator, and Lead in the Veterans Administration Healthcare System, and has prior experience as an Administrative Laboratory Director.

This course is part of the CAP Competency Assessment Hub.

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