Abstract
Learning from mistakes or failures is the purpose of a laboratory's event management
system. Laboratories that systematically and effectively learn from failures which
occur especially from small mistakes and problems rather than from consequential adverse
events, are rare. An effective event management program often requires a cultural
sea change that emphasizes a process of detection and reporting of errors that is
without reprisal. An approach to development of such an event management program is
described in this article. Steps of event management including engagement of the staff,
tools used, steps of evaluation, application to all elements of laboratory management,
and culture change necessary are discussed.
Keywords
quality - error - failure - Quality System Essentials
