Short Communications
Vol. 32 No. 2 (2017)
https://doi.org/10.4081/mm.2017.6572

Detectives in the laboratory: investigation of a seemingly unexplained error

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Received: 12 January 2017
Published: 7 July 2017
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Medical error, Laboratory.

Authors

Massimo De Paschale
massimo.depaschale@asst-ovestmi.it
Microbiology Unit, Hospital of Legnano, ASST Ovest Milanese, Legnano, Italy.
Sergio Finazzi
Clinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, Legnano, Italy.
Gianpietro Re
Clinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, Legnano, Italy.
Milvia Lotzniker
Clinical Chemistry Laboratory, Hospital of Legnano, ASST Ovest Milanese, Legnano, Italy.
Pierangelo Clerici
Microbiology Unit, Hospital of Legnano, ASST Ovest Milanese, Legnano, Italy.
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.

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Detectives in the laboratory: investigation of a seemingly unexplained error. (2017). Microbiologia Medica, 32(2). https://doi.org/10.4081/mm.2017.6572

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