Calgary Lab Services is the primary provider of Laboratory Services in the Calgary area. Laboratory data drive 70-80% of all health care costs. The data must be accurate and timely, protected and delivered to the care providers that need to know.

In the spring of 2005, a Revision Upgrade was done to the Lab Information system. One aspect of the upgrade introduced unexpected code, that changed the inherent patient identifier in the information. While no patients came to any harm, the impact has been enormous.

This presentation will discuss what happened, the points of failure for the error to get as far as it did, and other risks that have since been identified. As well, I will discuss what our quality processes were at that time, the changes that have been introduced and where we will be going in the future.