The page below is a sample from the LabCE course Patient Safety: Event Management in the Clinical Laboratory (by ASCLS). Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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Step 1 Document the Event

"A problem well-defined is a problem half-solved." - Anonymous

All staff should be trained to identify situations that are not compliant with an organization's operational processes and procedures. Upon discovering a situation, the staff person should document the information known about the occurrence. Documentation should:

  • Ensure the description is clear, uses specific terms, and no conclusions or assumptions are drawn.
  • Focus on information, not solutions.
  • Include information per the 4W/2H/1C Formula
    • What was affected?
    • Where did it take place?
    • When was it discovered?
    • Who discovered it?
    • How much was affected?
    • How often has this occured?
    • Consequences of the situation?
  • Include any immediate actions taken to care for the patient or donor and control harm.
  • Include any immediate actions take to prevent additional occurences.

Every event documented should be given a unique identifier that is recorded on a log for tracking purposes.