Republic of the Philippines

Department of Health
SOUTHERN ISABELA MEDICAL CENTER
RISK REGISTER
DIVISION Medical - Ancillary VERSION 2021-01
UNIT Pathology and Clinical Laboratories PERIOD COVERED January - June 2021

Issues: Internal/External 4.1.

Internal External
Interested
OBJECTIVE &
No. Parties 4.2a
TARGETS
Strength Weakness Opportunity Threat

Inadequate space to
Provision of space for
Strict compliance to the Citizen's Charter accommodate back-up Machine breakdown.
back-up machines.
machines.

Installation of
Limited number of computers Laboratory Information
used for manual encoding of System (LIS) and
Availability of automated machines that results. integrate to Hospital
Delayed delivery of
performs routine and special laboratory Information System.
result.
procedures. Internal:
Medical,
To ensure the timeliness Unsynchronized time in all the Synchronization of time Nursing, In-
1
of all laboratory results. wards in all the wards Patients
External: Out-
Patients
Point of Care Test
Additional tests such as
Only the following tests will be (POCT) for heart
cardiac markers must
Availability of ER Satallite Laboratory. done in the ER Satellite Lab: markers are not yet
be offered in the ER
CBC, Urinalysis, Hgt, iSTAT. available in the ER
Satellite Lab.
satellite laboratory.

Once Residency Unawareness of

Availability of Pathologists in the different
Program in Pathology is identifying and
sections of the laboratory to validate Unavailabilityof tables and lists
already accredited, relaying of critical
results prior to release (Clinical Lab, of critical values posted per
Residents will validate values/results by
Blood Bank, Histopathology, ER Lab) section in the laboratory.
the results during night Medical Technologist
from 8 AM -5 PM.
shifts. on duty.

FM-QMO-046.1 Page 1 of 1 REV 1/08.13.2019

 Republic of the Philippines
Department of Health
SOUTHERN ISABELA MEDICAL CENTER
RISK REGISTER
DIVISION Medical - Ancillary
UNIT Pathology and Clinical Laboratories

Risk 6.1.1 (may come from negative

Needs & Expectations internal and external issues or
No. 4.2b interested parties and their needs and Trigger
expectations)

1.1. Inadequate space to accommodate back-up

Machine breakdown.
machines.

1.2 Limited number of computers used for manual

encoding of results.
Delayed delivery of result.
Timely delivery of all
1
laboratory results.

1.4 Only the following tests will be done in the ER

Point of Care Test (POCT) for heart
Satellite Lab: CBC, Urinalysis, Hgt, iSTAT (PT/INR,
markers are not yet available in the ER
Na, K, Cl, Glu, BUN, Hgb/Hct, Anion Gap, Ionized
satallite laboratory.
Ca, TCO2).
 VERSION 2021-01
PERIOD COVERED January - June 2021

Opportunity 6.1.1 RISK ASSESSMENT

(may come from
positive internal and
external issues or
Risk Rating
(P/L + I + C)
Probability

interested parties and

Controls
Impact

their needs and RPN

expectations

Provision of space for back-

up machines.
1 1 1 3 3rd

Installation of Laboratory
Information System (LIS)
and integrate to Hospital
1 1 1 3 3rd
Information System.

1 2 1 4 3rd

Additional tests such as

cardiac markers must be
offered in the ER Satellite
1 1 1 3 3rd
Lab.
 Republic of the Philippines
Department of Health
SOUTHERN ISABELA MEDICAL CENTER

RISK REGISTER
DIVISION Medical - Ancillary VERSION
UNIT Pathology and Clinical Laboratories PERIOD COVERED

RISK CONTROL REVIS

(P/L + I + C)
Risk Rating
Probability

Control
No.

Impact

RPN
RECOMMENDED CONTROL PERSON RESPONSIBLE TIMEFRAME

1.1. Provision of back-up machine for routine test Pathologist, Chief Medical
January - June 2021
procedures. Technologist

1.2. Provision of additional computers and printers per

Pathologist, Chief Medical
section in the laboratory for manual encoding of January - June 2021
Technologist
laboratory results.

1.3. Provision of training on Basic Immuno Pathologist, Chief Medical

January - June 2021
HistoChemistry on Breast markers Technologist
1

1.4. Provision of additional Point of Care Test (POCT)

Pathologist, Chief Medical
such as cardiac markers (CKMB and Trop I) in the ER January - June 2021
Technologist
Sattelite Laboratory.
SOUTHERN ISABELA MEDICAL CENTER

RISK REGISTER
2021-01
January - June 2021

REVISED RISK

Reduction
Risk
EFFECTIVENESS OF ACTION
 Republic of the Philippines
Department of Health
SOUTHERN ISABELA MEDICAL CENTER

RISK REGISTER
DIVISION Medical Ancillary VERSION 2021-01
UNIT Pathology and Clinical Laboratories PERIOD COVERED January-June 2021

REFERENCE GUIDELINES
PROBABILITY IMPACT
SCORE RATING DESCRIPTION SCORE RATING DESCRIPTION Prepared By:

3 High (H) Very likely to happen or known to have 3 High (H) Consequence can have an adverse impact to the
happened in the past 2 years (with organization’s bottom lines or likely to result to customer
recent occurrence) complaints. Loss of reputation that may result to public
controversies or that would arouse public criticisms.

2 Medium (M) Likely to happen, or known to have
happened by more than 2 years (with
occurrence but not recent)
DIWATA FABROS-BAUSA,MD,FPSP
2 Medium (M) Consequence can have a moderate impact to organization’s
bottom lines or may result to customer complaints. Loss of
reputation of the organization from several stakeholder's
not necessarily the public. Process Owner

1 Low Can happen but not likely or having no 1 Low Consequence can have a minor impact on the
known occurrence in the past (never organization’s bottom lines and may not result to customer
occurred before) complaints. No loss of reputation to the organization

Noted By:
CONTROL RISK RATING

BUTCH LORETO O. GARCIA III,

SCORE RATING DESCRIPTION SCORE RATING DESCRIPTION
MD,MBA,FICS

4 No Control There is no control to address risk 1-2 4th Priority Accept and monitor
CMPS II / Division Head

3 Ineffective Existing control is ineffective to 3-5 3rd Priority Accept and monitor Approved By:
address risk

2 Partially effective Existing control is partially effective to 6-7 2nd Priority Implement actions from 6 months to 12 months
address risk
JOSE ILDEFONSO B. COSTALES JR.,
MD, MHA, CESE, FICS

1 Effective Existing control is effective to address 8-10 1st Priority Implement actions within 6 months
risk
Medical Center Chief II

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