Quality problems, incident investigation

System theory can be applied to incident investigation, reliability problems, quality problems, and other business losses. One of several reasons why system theory has received broad recognition relative to incident investigation is that it builds directly on current, verified process safety principles. In process safety, as in all other systems used to control risk to a business, there are three basic keys to controlling the risk (see Figure 3-4) ... 

It is suggested that internal evaluations be made of the quality of incident investigations to determine what improvements are necessary. Such evaluations often indicate the existence of culture problems demonstrated by the accepted practice for supervisors, management personnel above the supervisor level, and safety professionals to sign-off on shallow investigation reports. 

A well-conducted incident investigation has content-based validity. However, it is difficult to assess the other two types of validity. For criterion-based validity, we are not aware of what might be used as a criterion. We might look at the correlation between system causes of quality problems, as discovered by process-improvement teams, and the system causes of incidents. We would expect to find considerable overlap. If we failed to find this overlap, we might question the validity of either or both classes of investigations. 

Although this section may not appear immediately relevant to the problem of quality control within a routine hospital laboratory, it has been included to emphasize the fact that, at any stage in the whole procedure of any test, from the time of requesting an investigation to the time of furnishing the report, a mistake can lead to an erroneous and sometimes grossly misleading result, and that the contribution of the ward or out-patient department, etc., to the incidence of these errors has still not been fully appreciated. 

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