College of American Pathologists
Printable Version



CAP Today




August 2008
Feature Story

bullet Error reporting system

I read with interest the article in the June 2008 CAP TODAY, “Punching a Hole in Specimen ID Errors.” Since July 2005, the Division of Clinical Core Laboratory Services of the Department of Laboratory and Pathology at Mayo Clinic has been using the principles of the Just Culture to assess and address misidentification and mislabeling errors fairly and constructively. The Just Culture is an error reporting system that encourages employees to report events in the interest of patient safety. It emphasizes that most errors are unintended human errors that require re-engineering of systems or processes to prevent further similar errors. The Just Culture also stresses a team approach to address errors and to ensure the errors do not recur.

The Just Culture recognizes three types of errors, all with different responses:

  • Unintended human errors. These errors are noncognitive and unintentional and often caused by a flaw in the process or system. They require the supervisors to console the employee and to implement quality process improvements in the processes and systems.
  • At-risk behaviors. An example would be when employees do something they know is wrong, like taking a shortcut for the sake of expediency. Supervisors should coach the employee on why taking a shortcut may cause patient or employee harm or problems downstream from where the shortcut was taken.
  • Reckless behaviors. Employees who engage in this behavior know the result will be patient or employee harm. In these events, supervisors are expected to take quick action, including punishment.

Using this framework has helped us encourage the reporting of errors, make system improvements, and hold each other accountable for improving patient care.

Marx D. “Patient Safety and the Just Culture: A Primer for Health Care Executives.” April 17, 2001. Trustees of Columbia University in the City of New York.

James S. Hernandez, MD, MS
Assistant Professor of Laboratory Medicine and Pathology
Mayo Clinic, College of Medicine
Chair, Division of Clinical Core
Laboratory Services
Rochester, Minn.
bullet Patient identification

Thank you for a fine article on a Q-Probes report (“Punching a Hole in Specimen ID Errors”). I was happy to learn that the false economy of decentralized collection services versus professionally trained phlebotomy teams has become clear. I long advocated for these trained teams, not only to ensure accurate collections but also to provide an entry-level position from which might spring clinical laboratory assistants and medical technicians and technologists. But I was unable to sell this to administration.

Recently I visited a small stand-alone laboratory that special­ized in servicing nursing home patients over a fairly broad area of Houston. When I inquired about patient identification procedures, I was dismayed to learn that these patients have no wristbands or other positive identifiers. That many of these patients are mentally incompetent and don’t know who they are complicates the problem. The laboratory’s phlebotomists made rounds in the very early morning hours when few nursing home personnel are available to assist in accurately identifying patients, who may wander and swap beds during the night. The laboratorians seemed to be unconcerned, but it bothered me, and I wonder if it’s a national problem in nursing homes. Requiring ID bracelets on these patients would seem to be a simple and inexpensive solution. Or am I creating a solution in search of a problem?

P.R. Gilmer Jr., MD
Retired Pathologist