The wrong tube
Night of 5 to 6 November 2026. Yann Berger, technician, is running the blood bank at Val-Clair Centre. A blood group request comes in from the maternity unit.
Fictitious laboratory, people and documents. Screens recreated from the application.
Blood bank IH26-004131
06.1102:40 The blood group does not match the known identity.
On request IH26-004131, JadeIH blocks validation: the ABO differs from the patient's blood group identity. The guide asks for a new sample, with identity checked at the bedside.
IH26-004131→to Nonconformities PIP-2026-00431
03:52 The second tube settles it: it was not her blood.
The new sample gives the known identity again. Yann cancels the request, then “Report an NC” opens the form already filled in; he ticks “Caught in time (near miss)”.
Nonconformities PIP-2026-00431
08:10 Quality sorts it in one move.
Nadia Perrin, quality manager, qualifies it: high severity, “In-depth” level, Dr Hélène Vautier in charge. As long as the NC is open, JadeMP flags the record as blocking in the exchange queue with the LIS.
Nonconformities PIP-2026-00431
08:35 What had to be stopped is decided, and traced.
Dr Vautier answers the six containment questions, each dated in her name. No result had gone out: the clinical significance is assessed as “No impact”.
Nonconformities PIP-2026-00431
09.1109:00 The analysis is done by four people, on the same diagram.
Dr Vautier, Nadia, Yann and the maternity unit's head midwife fill in the Ishikawa at the same time. The whys lead to the cause: the procedure does not set when labelling takes place.
PIP-2026-00431→to Documents PROC-2026-00031
09:43 Two actions that act in the DMS.
With the analysis approved and signed, Dr Vautier creates “Review a document” on PROC-2026-00031 and “Retrain a user” for Sarah Bovet. The procedure immediately moves to “To revise”.
Documents INST-2026-00027
10.1107:05 The phlebotomist rereads the instruction, and the action closes.
In “My readings”, Sarah finds a new attestation for the bedside identification instruction. She signs it; at the next check, the NC's action becomes “Done” on its own.
INST-2026-00027→to Nonconformities PIP-2026-00431
17.1210:00 Verified effective, the NC closes and its report goes out.
The check goes back over the causes from the analysis; Nadia concludes “Effective” and signs. The NC closes, the closure report goes to the record, and Yann receives what was done.
What this story shows
Next story: A procedure that changes- An NC is created where the deviation is seenFrom JadeIH, a piece of equipment, the scope or a finding, prefilled and linked.
- A cause you can act onThe analysis refuses generic causes, and every cause retained has its action.
- The LIS record follows the NCRecord status, blocking, then closure report, in a queue the LIS picks up.
