CLN Daily
Laboratory professionals are often called upon to solve complex problems, identify hidden sources of error, and implement corrective actions that improve patient care. At ADLM 2026, Monday afternoon’s scientific session — “It was Miss Peacock at the analyzer with the bad QC! Laboratory medicine ‘Clue:’ Root cause analysis edition” — will transform familiar laboratory challenges into engaging, detective-style investigations designed to sharpen participants’ problem-solving skills. Like the guilty character in a good “Whodunit?” the culprits behind clinical laboratory mysteries are rarely as obvious as they first appear.
Moderated by Jane Dickerson, PhD, DABCC, of Seattle Children’s Hospital, the session brings together three laboratory directors who share a common goal: helping laboratorians integrate root cause analysis into everyday practice. Drawing inspiration from murder mystery games such as “Clue” and “Murdle,” the presenters will guide attendees through realistic scenarios requiring investigation, critical thinking, and active participation.
The session opens with Mark Marzinke PhD, DABCC, FADLM, of Johns Hopkins University, who will do a case-based discussion about uncovering the “mistaken identities” that can kill the accuracy of your laboratory results. Specifically, he will discuss errors that occur during the preanalytical phase of testing due to a range of suspects, including incorrect patient identification, botched specimen collection, and poor sample handling. Through interactive investigation, attendees will follow the clues and explore how systematic root cause analysis can uncover the culprits.
Next, Dickerson will present “the curious case of QC failure,” an analytical-phase mystery that examines quality-control challenges. She will advise laboratorians on how to distinguish symptoms from true root causes so they can develop the best possible corrective actions. Just when attendees think they have solved the case, another clue may point them in an unexpected direction. Her presentation highlights that systemic solutions require understanding why an error occurred, not simply documenting what happened on a case-by-case basis.
Steven Cotten PhD, DABCC, NRCC, FADLM, of the University of North Carolina, leads the final segment on “intercepted intelligence” from post-analytical errors, emphasizing the importance of accurately interpreting and reporting results after testing is complete. Participants will probe how these events can quietly infiltrate care, impacting clinical decisions and patient outcomes.
Beyond individual cases, the session aims to address an important challenge facing the profession: variability in how laboratories investigate and learn from errors. Drawing on their collective experiences as laboratory directors, the presenters were motivated to create an engaging approach to problem-solving after observing differences in training and quality practices. By emphasizing error detection, root cause analysis, countermeasure design, and monitoring effectiveness, they hope to equip laboratorians with practical tools that can strengthen quality systems and foster cultures of continuous improvement.
The session’s message is timely, as laboratories continue to navigate workforce shortages, financial pressures, and rapidly evolving technologies. These constraints make proactive risk identification and mitigation strategies more important than ever. By combining education with audience participation and a touch of detective work, the presenters hope attendees leave with renewed confidence in applying root cause analysis to challenges encountered throughout the testing process. After all, solving the mystery of who committed the error is not nearly as important as learning how to prevent the next one.