The frequency and level of risk determine the colors to be applied to the process map steps for visualization of areas needing focused action. The assessment team has determined that any risks assessed as either 2 or 3 (yellow or red) must be addressed. For example, for this test, it could be catastrophic if the specimen is collected on the wrong patient, even if the possibility was remote, because the patient who should have been tested may not receive treatment. This could result in death or permanent loss of function. There is no system in place, such as a delta check, that could alert the testing staff to a patient identification error.
