PROFICIENCY TESTING FAILURE REVIEW

PT Program: _____________ PT Event ID#: __________________

Date Tested: _________ Date Results Received: __________

Failed Analyte(s): _________________________________________

Investigative Steps Taken:___________________________________________

__________________________________________________________________________________________________________________________________

Suspected Reason for PT failure: ______________________________________

__________________________________________________________________________________________________________________________________

Steps Taken to Correct Problem or Prevent Recurrence: ___________________

___________________________________________________________________________________________________________________________________________________________________________________________________

Name(s) of those involved in the PT testing process?______________________

How were they involved in the testing process?______________________ _________________________________________________________________

For each individual named above, was training and/or technical assistance provided consistent with the PT failure reason? Yes ___ No ___

Were patient results affected during this time? Yes ___ No ___

If yes, were providers notified of the problem? Yes ___ No ___

Maintain copies of any notification to providers.

Additional Comments: ______________________________________________

_________________________________________________________________

_________________________________________________________________

Tech: _______________________________________ Date: __________

Laboratory Director: ____________________________ Date: __________

Quality America