Walk a specimen mix-up to prevention
Respond to a specimen mix-up by containing patient risk and identifying failure modes for prevention.
Near miss Two outpatient lavender tubes may have been mixed at adjacent draw chairs. No result has released yet. Wrong-patient result risk is high severity even without harm. FMEA lens Contain the effect, then move upstream to the failure mode Failure-mode thinking asks how the process allowed a risk to get this far. Reflex Recollect and close the report. The fix moves upstream from redraw to process design. FMEA improves safety by naming how a process can fail before the failure reaches the patient. 01 Contain 02 Trace 03 Prevent Contain current risk Boundary
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