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Middleware and the Clinical Hematology Laboratory


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Focus on Patient Safety Issues

Slide 18

February 2009

When you look at revised reports and near misses in the hematology laboratory, you will find that they may be related to revised differential counts, revised platelet counts due to clotted specimens or EDTA associated clumping, or it may be because a SOP was not followed through.  In other words, the memory was faulty: the tech did a scan and release instead of a manual differential, they forgot to have a second review by a senior tech or physician, etc.  In addition, there may be clerical errors as data is entered into the LIS or the worst possible scenario:  mixing up slides and paperwork.  Think about how many sticky notes your laboratory has on the wall and how dependent we are on those as well as our individual memories.  When we have these dependencies, I guarantee you that we will end up with patient safety issues. 

Focus on Patient Safety Issues


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