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The page below is a sample from the LabCE course The Basics of Non-Conforming Event Management for Clinical Laboratory Services. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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Analysis

Once the investigation is underway or completed, the team should analyze the process and all associated records that were collected. Look for trends, if any, in the sources of the occurrence. This is when performing a root cause analysis (RCA) becomes helpful in determining the cause of the NCE.
A frequent tool used in RCA is the concept of Five Whys analysis, in which the investigator continually asks, why did this happen? Keep drilling down by asking “why” at each step of the process until an actionable cause can be identified.