Root Cause Analysis : Peritoneal Fluid
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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 : Peritoneal Fluid
- 1. RCA of Incident : Peritoneal Fluid for Amylase Team Members 1. Reginal Bantin (Pegawai Sains Kajikuman C48 Menanggung) 2. Nurulamin Abu Bakar (Pegawai Sains Biokimia C44) 3. Alexander Beemer (Pegawai Sains Kajikuman C41) 4. Juanita Ling (Pegawai Sains Biokimia C41) 5. Sister Yong Suk Moi (Jururawat U32 KUP, Surgical Department)
- 2. Brief Summary of Incident 23rd September 2012 – Peritoneal fluid for amylase requested, sample sent same day at 6.30pm. Specimen received and signed by ab staff RAF. 24th September 2012 – No result received by ICU at 8am. ICU called lab at 9.30am and 12.40pm, MLT Sabinah informed result not yet ready. Mr. Ashok called at 1.15pm – Informed by Juanita that specimen only received by biochem in the morning.
- 3. Define the problem (Using process diagram / sequence of events) Ref Date Time Location Event Description Key person(s) involved Comment/ Queries 23 Sept 2012 1830hrs ICU Dr. Mohd Zakri requested peritoneal fluid for amylase, sample sent to lab. Sample received by MLT Rafidah. Doctor , MLT Was the sample marked urgent? Were there any effort by the requesting doctor to inform the lab regarding the urgency of the sample? 24 Sept 2012 0930hrs ICU ICU called lab regarding specimen result. Lab informed result not ready. QC not in for analyzer. Lab Staff Sample was not marked as urgent, sample treated as routine. Analyzer QC having problems. 1240hrs ICU ICU called lab regarding specimen result. MLT Sabinah informed result not ready, lunch break. Lab Staff 1315hrs ICU Mr Ashok called lab regarding specimen result. Science Officer Juanita informed specimen was only received in the morning, result given thru phone. Lab Staff Were there sufficient information given to doctor regarding the cause of sample delay? Is the test stated in the Critical Tests List for biochemistry lab?
- 4. Staff/MO who collect? Specimen collection PPK send to lab Received by MLT on call Biochem received Run Test Result Delay Form didn't notify request as urgent Not in lab policy Logbook send in ordinary way No urgent noted not indicated to say urgent Treat as ordinary sample Send to biochem unit on 24th sept Specimen clotted Technical Problem QC Pleural fluid for amylas is not in Critical Test List. *LTAT AMylase is 45mins 24TH SEPTEMBER 201223RD SEPTEMBER 2012 Identify contributory factors (cause effect diagram/fishbone /5why)
- 5. Plan of action No Root cause Action Responsibility Date due 1 2 3 Non-urgent test was requested during oncall hours. Equipment evaluation Urgent Tests List needing update Requesting doctor to call up lab in- charge to run non-urgent test during oncall hours. Equipment used to run amylase must be evaluated again for QC consistency Ward representatives and laboratory in-charge to review Urgent Tests List Requesting doctor Laboratory in- charge Doctors and Laboratory Officers Immediate Immediate As soon as possible
- 6. The End