Detectives in the laboratory: investigation of a seemingly unexplained error

Detectives in the laboratory: investigation of a seemingly unexplained error

An unexplainable error that occurred in the normal laboratory routine is described: a positive result for the anti-HCV antibodies detection was found in a single blood tube collected from a patient, while the other samples taken simultaneously were anti- HCV negative. After the first checks that did...

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Main Authors: Massimo De Paschale, Sergio Finazzi, Gianpietro Re, Milvia Lotzniker, Pierangelo Clerici
Format: Article
Language:English
Published: PAGEPress Publications 2017-07-01
Series:Microbiologia Medica
Subjects:
Medical error
Laboratory.
Online Access:http://www.pagepressjournals.org/index.php/mm/article/view/6572
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spelling doaj-982b1da75c0f4995a9544e91cbe1132e2020-11-25T04:00:51ZengPAGEPress PublicationsMicrobiologia Medica 2280-64232017-07-0132210.4081/mm.2017.65725333Detectives in the laboratory: investigation of a seemingly unexplained errorMassimo De Paschale0Sergio Finazzi1Gianpietro Re2Milvia Lotzniker3Pierangelo Clerici4Microbiology Unit, Hospital of Legnano, ASST Ovest Milanese, LegnanoClinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, LegnanoClinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, LegnanoClinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, LegnanoMicrobiology Unit, Hospital of Legnano, ASST Ovest Milanese, LegnanoAn unexplainable error that occurred in the normal laboratory routine is described: a positive result for the anti-HCV antibodies detection was found in a single blood tube collected from a patient, while the other samples taken simultaneously were anti- HCV negative. After the first checks that did not highlight any special problems, an internal committee composed of the chiefs of the units involved was established. This committee, using investigative analysis with the Root Causes Analyses model was able to understand the error.http://www.pagepressjournals.org/index.php/mm/article/view/6572Medical errorLaboratory.
collection DOAJ
language English
format Article
sources DOAJ
author Massimo De Paschale
Sergio Finazzi
Gianpietro Re
Milvia Lotzniker
Pierangelo Clerici
spellingShingle Massimo De Paschale
Sergio Finazzi
Gianpietro Re
Milvia Lotzniker
Pierangelo Clerici
Detectives in the laboratory: investigation of a seemingly unexplained error
Microbiologia Medica
Medical error
Laboratory.
author_facet Massimo De Paschale
Sergio Finazzi
Gianpietro Re
Milvia Lotzniker
Pierangelo Clerici
author_sort Massimo De Paschale
title Detectives in the laboratory: investigation of a seemingly unexplained error
title_short Detectives in the laboratory: investigation of a seemingly unexplained error
title_full Detectives in the laboratory: investigation of a seemingly unexplained error
title_fullStr Detectives in the laboratory: investigation of a seemingly unexplained error
title_full_unstemmed Detectives in the laboratory: investigation of a seemingly unexplained error
title_sort detectives in the laboratory: investigation of a seemingly unexplained error
publisher PAGEPress Publications
series Microbiologia Medica
issn 2280-6423
publishDate 2017-07-01
description An unexplainable error that occurred in the normal laboratory routine is described: a positive result for the anti-HCV antibodies detection was found in a single blood tube collected from a patient, while the other samples taken simultaneously were anti- HCV negative. After the first checks that did not highlight any special problems, an internal committee composed of the chiefs of the units involved was established. This committee, using investigative analysis with the Root Causes Analyses model was able to understand the error.
topic Medical error
Laboratory.
url http://www.pagepressjournals.org/index.php/mm/article/view/6572
work_keys_str_mv AT massimodepaschale detectivesinthelaboratoryinvestigationofaseeminglyunexplainederror
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AT gianpietrore detectivesinthelaboratoryinvestigationofaseeminglyunexplainederror
AT milvialotzniker detectivesinthelaboratoryinvestigationofaseeminglyunexplainederror
AT pierangeloclerici detectivesinthelaboratoryinvestigationofaseeminglyunexplainederror
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