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Tarangnan Community Hospital — Clinical Laboratory

Score the Risk. Treat It in Order.

Every identified risk is scored, treated, and recorded in the Risk Register (F-QM-009-A-V0).
INFOGRAPHIC IG-10
Source: LAB-QM-009
Version V0 — DRAFT

The matrix — §5.4 (Severity × Likelihood)

Low likelihood
(rare / unlikely)		Medium
(possible)		High
(probable / frequent)
High severity
(critical / severe)		MediumHighCritical
Medium severity
(moderate impact)		LowMediumHigh
Low severity
(minor / negligible)		LowLowMedium
Critical / High — unacceptable: immediate intervention, preventive barriers, and notification of the Pathologist and Hospital Director.
Medium — tolerable with active controls: action plan required, with a defined monitoring frequency.
Low — acceptable: routine monitoring under standard operating procedures.

Six risk domains — §5.2

1 · Organizational & Governance — staffing levels, competency gaps, delegation, resource constraints.
2 · Pre-Examination & Phlebotomy — patient misidentification, labeling errors, hemolysis, uncentrifuged delays, transport problems.
3 · Analytical & Equipment — analyzer breakdowns, expired reagents, calibration drift, water quality, IQC/EQA failures.
4 · Post-Analytical & LIS — transcription errors, delayed critical-value reporting, amended reports.
5 · Biosafety & Environmental — sharps injuries, spills, laboratory-acquired infections, chemical and electrical hazards, typhoon/flood disruption.
6 · External & Referral — referral delays (Samar Provincial Hospital), specimen transit integrity, utility outages, supply-chain interruptions.
Re-assess immediately when (§5.3): new equipment or methods are commissioned · workflow, facility, or LIS changes · occurrence or near-miss trends · CAPA findings · audit nonconformities.
1 · Elimination
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2 · Engineering controls
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3 · Administrative controls
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4 · PPE (last line)
Treat in this order (§5.5): eliminate the hazard first; then engineering controls (e.g. biosafety cabinet, centrifuge safety buckets); then administrative controls (e.g. two-identifier verification, SOPs, dual verification); PPE is the last line. Each plan names a responsible person, steps, target date, and budget in F-QM-009-A-V0. After controls, re-score: if the residual risk is still unacceptable, add controls — or suspend the activity until the Pathologist and Hospital Director authorize otherwise.