How do we know when a problem or non-conformity has occurred? The identification of NCEs may come from several places, both within and outside the laboratory.
High-risk sources of NCEs include adverse events, which are occurrences that may pose a significant risk to patient safety. Adverse events carry a high degree of risk and need to be managed with top priority, requiring immediate investigation and implementation of corrective actions. Of even more serious nature and priority are sentinel events. The Joint Commission defines a sentinel event as an unexpected occurrence that involves a death, serious physical or psychological injury, or the risk thereof. Of a lesser degree of severity, but still of significance is the near-miss event. These are all obvious and definite times to begin a corrective action process.
