Corrective Action Documentation Form - Wp Engine Page 2

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2016 PROGRAM GUIDE
I
Proficiency Testing Service
I
AAB
Proficiency Testing Action Form
LABORATORY NAME: ____________________________________________________________________________
Section:
__________________________________________________________________________________
Completed by: ___________________________________________________________________________________
Core lab Manager / Department Supervisor: ____________________________________________________________
Problem: _______________________________________________________________________________________
Attach documents as needed
Corrective Action/Preventive Action: _______________________________________________________________
Attach documents as needed
Reviewed by:
Laboratory Manager ____________________________________________________________ Date: ______________
Medical Director _______________________________________________________________ Date: ______________
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
PROFICIENCY TEST CORRECTIVE ACTION CHECKLIST FORM
Laboratory Name: ___________________________________________________________
CLlA #: __________________
Testing Event: ______________________________________________________________
Year: ____________________
Proficiency Testing Module: ___________________________________________________
Analyte: __________________
Date PT Sample Rcvd __/__/___
Test Date: __/__/___
Report Date: __/__/___
Sample #:___________________ Reported Results: ___________________
Expected Range: ___________
Expected Results: ____________ Repeat Analysis Result _______________ (Original or new specimen)
Sample #:___________________ Reported Results: ___________________
Expected Range: ___________
Expected Results: ____________ Repeat Analysis Result _______________ (Original or new specimen)
Sample #:___________________ Reported Results: ___________________
Expected Range: ___________
Expected Results: ____________ Repeat Analysis Result _______________ (Original or new specimen)
Sample #:___________________ Reported Results: ___________________
Expected Range: ___________
Expected Results: ____________ Repeat Analysis Result _______________ (Original or new specimen)
Sample #:___________________ Reported Results: ___________________
Expected Range: ___________
Expected Results: ____________ Repeat Analysis Result _______________ (Original or new specimen)
I. Does this failure represent unsatisfactory performance for this analyte, specialty, or subspecialty?
Y / N
2. Does this failure represent unsuccessful performance for this analyte, specialty, or subspecialty?
Y / N
(Unsatisfactory performance for two events in a row or two out of three consecutive testing events:
------------------------------------------------------------------------------------------------------------------------------------------------------------------
PT Failure Classification:
Submitted Late
Lack of Consensus
Failure to Submit
Clerical Error
Equipment Error
Educational Challenge
Trend / Bias
Other
FINDINGS:__________________________________________________________________________________________________
___________________________________________________________________________________________________________
CORRECTIVE ACTION: _______________________________________________________________________________________
___________________________________________________________________________________________________________
COULD THIS ERROR AFFECT PATIENT RESULTS?
Y / N
If yes, state course of action: ___________________________________________________________________________________
[Review process to be modified by each lab to what is appropriate for that lab]
Investigated by: ______________________________________________________________________ Date: ___/___/____
Technical Consultant/Supervisor: ________________________________________________________ Date: ___/___/____
Laboratory Director: ___________________________________________________________________ Date: ___/___/____
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2016 PROGRAM GUIDE | Proficiency Testing Service | AAB

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