Detectives in the laboratory: investigation of a seemingly unexplained error

Abstract

An unexplainable error that occurred in the normal laboratory routine is described: a positive result for the anti-HCV antibodies detection was found in a single blood tube collected from a patient, while the other samples taken simultaneously were anti- HCV negative. After the first checks that did not highlight any special problems, an internal committee composed of the chiefs of the units involved was established. This committee, using investigative analysis with the Root Causes Analyses model was able to understand the error.

Keywords

• Medical error
• Laboratory.