[Adaptations to the incidental cases encountered at the division of clinical laboratory]

We analyzed 4 cases that were not determined as incidents and another 7 cases determined as incidents, found at the department of clinical laboratory of us from April 2009 to March 2010. The former cases were, excess values of LD, and Cl, and glucose leveled as 0 mg/dl incorrectly, and misdirected blood samples at the ER. Our routine equipment and sample flow did not detect these false values. Resetting for auto dilution system and secondary check by every worker were reconsidered for these measurements. Antiseptic drug usage was notified by clinicians, and actually affected to the excessive Cl value. Real incidents were, two unprocessed samples, leakage of a sample, missing processes that caused delay of clinical practice, mixed up sample labels, a lost narcotic patch during cardiac ultrasonography. A lack of checking, carelessness, and accidental mistakes were reevaluated and reminded for workers on the duties. Also inadequate pharmaceutical knowledge and responsibilities of this section might severely affect on these lessons. Efforts were taken so that all workers shared the accurate information. Code blue cases are defined here as those of life-threatening events and sudden vital changes occurred in highest emergency, involve all health care workers, patients, and families. It is very important here to keep regular trainings for workers to cope with such events as well as preemptive assessments on environment and underlying risks in our laboratory. In line with the continuous advances in clinical medicine, medical safety managements are growing issues. To achieve safer environment and minimize various type of risks in the hospital, these incidents are to be assessed and reported regularly.