Abstract
Committee Membership
Foreword
1 Scope
2 Definitions
3 Overview of a Nonconforming Event Management Program
4 Human Error
5 Creating a Culture to Discover and Report Nonconforming
Events
5.1 A Just Culture
5.2 Nonconforming Event Management Program Support
5.3 Detecting or Discovering Nonconforming Events
6 Initiating a Nonconforming Event Report
7 Remedial Action
7.1 Distinction Between Remedial and Corrective Action
7.2 Remedial Action as Corrective Action
8 Investigation
8.1 Path of Workflow
8.2 Investigating the Nonconformance
8.3 Documentation of Investigation
8.4 Feedback
9 Short-term Corrective Action
10 Classification
10.1 The National Center for Patient Safety (NCPS) - Safety
Assessment Code (SAC)
10.2 Laboratory Event Classification rective Action
11 Analysis of Event Information and Data Presentation
11.1 Reporting Data
11.2 A Medical Laboratory Example
12 Management Review and Referral to Process Improvement
for Long-term Corrective Action
12.1 Management Review
12.2 RCA
12.3 When to Perform RCA
12.4 Conducting an RCA
12.5 Commonly Identified Root Causes
12.6 Process Improvement
13 Application of Nonconforming Event Management to a
Laboratory Example
13.1 Initiating the Nonconforming Event Report
13.2 Remedial Action
13.3 Investigation - How It Happened
13.4 Investigation - Who and What
13.5 Investigation - Why It Happened
13.6 Documentation of Investigation
13.7 Short-term Corrective Action
13.8 Classification
13.9 Review and Referral
13.10 RCA
13.11 Process Improvement
14 Last Words of Advice
References
Additional Resources
Appendix A1. Sample of a Simple Generic Nonconforming Event
Report
Appendix A2. Sample Laboratory Nonconforming Event Report
Appendix A3. Second Example of a Laboratory Nonconforming
Event Report Form
Appendix A4. Example of Another Laboratory Event Management
Form
Appendix B. The Safety Assessment Code (SAC) Matrix
Appendix C. Data Collection Tools
Appendix D. Investigation and Data Reporting Tools
Appendix E. A Formal Process for Using Root Cause Analysis
(RCA) and Related Quality Tools
Summary of Delegate Comments and Committee Responses
The Quality Management System Approach
Related CLSI Reference Materials