Module 3, Lesson 2 - Process Overview

Patient is going to surgery and autologous unit previously donated by the patient cannot be located.

In anticipation of surgery, a unit of autologous blood is drawn from the patient. However, the unit is not tagged properly and it mistakenly goes back into general inventory.

Below is a timeline that illustrates where in the process the event was first discovered and where earlier in the process the event actually occurred. The distance between those two points is referred to as the vulnerability space.

This space indicates potential weakness in an organization's process and the need for additional or more effective barriers.


Page 4 of 5 - Detection