Event management: the heart of the quality program.
Learning from mistakes or failures is the purpose of a laboratory's event management system. Laboratories that systematically and effectively learn from failures which occur especially from small mistakes and problems rather than from consequential adverse events, are rare. An effective event management program often requires a cultural sea change that emphasizes a process of detection and reporting of errors that is without reprisal. An approach to development of such an event management program is described in this article. Steps of event management including engagement of the staff,  tools used, steps of evaluation, application to all elements of laboratory management, and culture change necessary are discussed.
Department of Pathology, University of Texas Health Science Center, San Antonio, Texas 78229-3900, USA. olsonj@uthscsa.edu
John D
JD
Olson
Chantal R
CR
Harrison
D019411:Clinical Laboratory Techniques / Q000379:methods* / Q000592:standards*; D006801:Humans; D012308:Risk Management / Q000379:methods* / Q000592:standards*