LABORATORY INCIDENT REPORT

Document the incident: Todays Date: ____________________

Health Department Name: ____________________________________________________ Who was involved? In-house External, person involved (if any) _______________ Organization ______________ When did it happen? Date of incident ____/____/____ Time: _________________________

How did the incident come to your attention? Was involved Reported to me Other _________________________ Type of incident: Clerical/Data Entry Communications Proficiency Testing Testing Process Result Reporting Safety Other ____________

Describe the incident: (include multiple versions when applicable)

That on or about (date of incident) at 11pm upon arrival in the lab I saw Clyde, the on-duty medtech, was already done running the serology test and computing the absorbance. He, then, ask for my help to check the testosterone result because the result that he got was high (0.20-0.95). I recomputed the result of the absorbance and the result that Ive got was higher (calibration 2.85 at insert:8.73). We, then, decided to release the lower result which is the one computed by Clyde. That on (date when was the call) at (time) I/We received a call from Gensens Inc. confirming the result of the testosterone that I/we released due to its alarming result. I, then, make a 2nd running of the test and the result of absorbance is still high (0.686)=insert result 14..63 and calib result 8.07 and for this reason I did not release the same and endorsed to Mr. Aaron, the Chief Medtech.

Incident Reported By: _________________________________ Signature Date Date __________________________________ Signature