BDP CQI Form
If this issue affects immediate patient care or staff safety, notify your supervisor ASAP (completing CQI does not exclude)
Date
*
/
Month
/
Day
Year
Date Picker Icon
Status
Departments Involved
COMMUNICATION WITH PATHOLOGIST
Accessioning/Verification
Grossing
Embedding
Microtomy
Staining
Collation
Equipment Malfunction
IT
Case Manager
Safety
Facility
Client Services
Courier
COMMUNICATION WITH PATHOLOGIST
NEEDS IMMEDIATE FEEDBACK: PLEASE ADVISE
NO VARIANCE: FYI ONLY
Accessioning/ Verification Issues
Not Following Proper Protocol
Incorrect Dropdown selection
Typographical
Missed TS
Grossing Issues
Not Following Proper Protocol
Typographical
Incorrect Dropdown/Template selection
Wrong Run Selection
Missing Tissue
Found Tissue
Embedding Issues
Not Following Proper Protocol
Improper Orientation
Air bubbles that cause subsequent microtomy problems
Missing Tissue
Found Tissue
Microtomy Issues
Not Following Proper Protocol
Switching Cases/Pulling Incorrect Block
Chuncked Out/Cut Away
Wrong Kind of Slide
Missing/Misplaced Block
Staining Issues
Not following protocol/wrong staining protocol selection
Variation in stain
No coverslip
Contaminated reagents
Stain did not work properly
Tissue Washed
Collation Issues
Not Following Proper Protocol
No Master Log
No Verification Log
TS Not Resolved
Slides mixed/out of order
Equipment Malfunction Issues
Cassette Printer
Processor
Embedding unit
Micrtome
Slide printer
Prisma
Bond
Artisan
Cryostat
Refrigerator
Freezer
IT Issues
Not Following Proper Protocol
Missing Info
System Error
User Error
Master Log
Electronic Order
Copia
Case Manager Issues
Coding
Dictation
Ancillaries
Client Communication
Filing
Safety Issues
Ergonomics
Near Miss
In conjunction with Injury
Other
Facility Issues
Plumbing
Structural
HVAC
Furniture
Air Quality
Other
Client Services
Specimen Return
Internal Error
Client Error
Supply/Inventory
Hardware
Complaint
Courier
Missed Pickup
Late Pickup
Supply Issue
Manager Communication
Client Complaint
Case Number
*
Put N/A if no case number available
Client (Provider)
*
Put N/A if no provider available
Person Reporting
*
Investigative Findings
*
What happened?
Improvement Ideas
Upload File
Take a photo
Process Changes recommended by Supervisor
QM Comments
Send to
Laboratory Director
Practice Administrator
Practice Administrator Comments
Laboratory Director Comments
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