CAP Pro Course - Laboratory Management - Investigating Occurrences (2026 & 2027)

Author: Lynne Brodeur, MA, MLS(ASCP)CM
Reviewers: Laurie Bjerklie, MA, MLS(ASCP)CM and Julie Ann West, PhD, MLS(ASCP)CMSMCM

Continuing Education Credits

Objectives

  • Define "occurrence" and identify the role of occurrence investigation in the Quality Management System (QMS).
  • Explain how to build an occurrence investigation process that encourages a culture of employee engagement.
  • Identify the primary elements needed for investigating occurrences and discuss their functions.

Course Outline

  • Define "occurrence" and identify the role of occurrence investigation in the quality management system.
      • Overview of Occurrence Investigation
      • The Role of Occurrence Investigation in the Quality Management System
      • Quality Improvement Philosophies and Tools
      • Andrea is the new quality manager at a small county hospital. This is her first managerial position. One of her first duties is to investigate the blo...
      • Bob is a medical laboratory scientist in the coagulation department of a large metropolitan hospital. Today, he received a clotted prothrombin time (P...
      • Why should established benchmarks be a part of laboratory quality assurance?
      • Which of the following statements about occurrence investigation is incorrect?
      • Which of the following is a definition of a benchmark?
  • Explain how to build an occurrence investigation process that encourages a culture of employee engagement.
      • "Just Culture"
      • Algorithmic Approach to Determining Cause of Occurrence, Response, and Appropriate Intervention
      • Breaking Down Silos: Perspectives and Collaboration
      • An employee has been retrained and assessed for competency after two separate occurrences resulting from the employee's failure to label sample aliquo...
      • A new employee reported an amylase result beyond the upper limit of the reportable range. The error was caught when the chemistry supervisor reviewed ...
      • Recently, the laboratory manager has addressed a problem with two staff members regarding improperly labeled specimens following blood collection. Nei...
      • Specimens coming from the emergency and surgery departments are collected and/or prepared for submission to the laboratory by non-laboratory personnel...
  • Identify the primary elements needed for investigating occurrences and discuss their functions.
      • Primary Elements in Occurrence Investigation Process
      • Element #1: Detection and Reporting
      • Element #1: Detection and Reporting, continued
      • Element #2: Immediate Error Response and Investigation
      • Element #3: Data Review and Analysis (Tracking and Trending)
      • Pareto Chart
      • Root Cause Analysis
      • Root Cause Analysis: "5 Whys" Technique
      • Root Cause Analysis: Cause-and-Effect (Fishbone) Diagram
      • Root Cause Analysis: Flowchart of Work Process
      • Element #4: Process Improvement and Recurrence Prevention
      • Interventions for Reducing Errors
      • A laboratory manager received a report from staff regarding repeated quality control (QC) failure on one of the immunohematology analyzers. What would...
      • A laboratory manager received a report from staff regarding the repeated quality control (QC) failure on one of the immunohematology analyzers. The ma...
      • John is the laboratory director for a 500-bed metropolitan hospital. Recently, the hospital merged with a smaller hospital in the area, and John was n...
      • Which of the following choices would be considered a strong intervention for reducing errors long term?
      • What should be avoided when completing an occurrence investigation report?
      • In reviewing the quarterly occurrence report statistics, you notice an increase in the number of unlabeled specimens. What should be your course of ac...
      • Which one of the following features is characteristic of effective occurrence reporting forms?
  • References
      • References

Additional Information

Level of Instruction: Intermediate
Intended Audience: This program is designed as an educational and training tool for MLS and MLT personnel, medical laboratory science students and interns, pathology residents, and practicing pathologists.
Author Information: Lynne Brodeur, MA, MLS(ASCP)CM, holds a master of arts degree in teaching. She is a full-time lecturer at the University of Massachusetts Dartmouth and works per diem in Clinical Chemistry at St. Luke's Hospital in New Bedford, MA.
The author has no conflict of interest to disclose.
Reviewer Information:
Laurie Bjerklie, MA, MLS(ASCP)CM, is a Lead Education Developer. She earned a B.S. in Medical Laboratory Science from the University of North Dakota and an M.A. in Curriculum and Instruction from Saint Xavier University. She has over 15 years of experience in higher education and has held program director and faculty positions in both MLT and MLS programs.
Dr. Julie Ann West is certified by the American Society for Clinical Pathology (ASCP) as a Medical Laboratory Scientist (MLS) and as a Specialist in Microbiology (SM). In addition, Dr. West has earned a PhD in Public Health - Infectious Disease Epidemiology - and is Certified in Public Health (CPH) by the National Board of Public Health Examiners. Dr. West is experienced as a Technical Specialist, Safety Officer, Educator, and Lead in the Veterans Administration Healthcare System and has prior experience as an Administrative Laboratory Director.

This course is part of the CAP Competency Assessment Hub.

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