Root Cause Analysis, Delay Sending of Specimen to Referral Laboratory (Sample with Prior Appointment)
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Root Cause Analysis for Solving Incident Reports in for Healthcare Setting, Hospital Sibu Sarawak
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Root Cause Analysis, Delay Sending of Specimen to Referral Laboratory (Sample with Prior Appointment)
- 1. RCA of Incident : Rejected Specimen for Phagocytic Function Test IMR Team Members 1. Reginal Bantin 2. Alexander Beemer Mijen 3. Siti Syartinah Sharkawi 4. Noel Ting Yong Yin 5. Saiful Ungo 6. Siti Syazwana Taip 7. Flora Denis
- 2. Brief Summary of Incident 23rd April 2013 – PMW20 Blood collected for patient Eric Hernandez Sylvester for Immunodeficiency Screening, appointment set with IMR on 24th April 2013. 23rd April 2013 – Serology sent sample to IMR with Poslaju. 25th April 2013 – IMR received sample, reject sample due to not fresh and missed appointment.
- 3. Define the problem (Using process diagram / sequence of events) Ref Date Time Location Event Description Key person(s) involved Comment/ Queries 23rd April 2013 N/A Ward PMW20 Blood collected for patient Eric Hernandez Sylvester for Immunodeficiency Screening, appointment set with IMR on 24th April 2013. Ward staff PMW20 Did the ward inform the lab on the sample urgency? 23rd April 2013 Office Hours Lab Serology sent sample to IMR with Poslaju. Lab Staff for Sending section Did lab staff aware on urgent samples? Did lab staff confirm with ward staff on the sample urgency? 25th April 2013 Office hours IMR, KL IMR received sample, reject sample due to not fresh and missed appointment. IMR Staff
- 4. Specimen collection Receive by Lab Staff, packed Sent to IMR with Poslaju Sample received by IMR IMR Reject, sample not fresh Report sent to Hospital Sibu Lab has no list of urgent tests requiring sending within 24 hrs 23rd April 2013 Identify contributory factors (cause effect diagram/fishbone /5why) 25th April 2013 Sample not fresh. Sample missed appointment date Lab Staff not aware of sample urgency Sample urgency not stated properly Sending record does not include delivery method
- 5. Plan of action No Root cause Action Responsibility Date due 1 2 3 Sending record does not include delivery method Lab Staff not aware of sample urgency Lab has no list of urgent tests requiring sending within 24 hrs To improve laboratory outsourced sending record to include delivery method. To improve communication by double confirming on sample urgency with the requesting doctor. To list down all known urgent outsourced tests which require samples to arrive at outsourced laboratory within 24 hours. Lab Staff Lab Staff and Ward Staff Lab Staff Immediate Immediate Immediate
- 6. The End