This document summarizes the experience of the laboratory at Hospital Sibu in managing blood film for malaria parasite (BFMP) testing in 2012. It discusses the monthly BFMP workload and positivity trends, prevalence of different malaria species, turnaround times and compliance with the 1-hour laboratory target. It also describes two cases where BFMP results were incorrectly reported initially and the root cause analyses and corrective actions taken. External quality assurance participation and training for on-call staff and hospital staff on BFMP smear preparation are also summarized.

1. Experience in BFMP
Management in Serology
Laboratory, Hospital Sibu
By Makmal Serologi
Jabatan Patologi Hospital Sibu

2. Introduction
 Blood Film for Malaria Parasite (BFMP) as both routine and
critical test in Sarawak.
 In Hospital Sibu, BFMP results adhere to 1-hour Lab Turn-
Around Time, for both office hours and after office hours
 Use Geimsa staining

3. 457
352
495
416
372
390
359
246
483
500
305
160
0
100
200
300
400
500
600
Monthly BFMP Slides Workload for 2012
Total BFMP Slides (4535)

4. 60
68
44
26
39
34
42
77
67
101
64
21
0
20
40
60
80
100
120
Monthly Trend for Positive Malaria Samples 2012
TOTAL POS (643)
Prevalence rate of positive slides

5. 14%
24%
4%
58%
0%
Percentage of Malaria Species from
patient BFMP slides for 2012
P.Falciparum (90) P. Vivax (157) P.Malariae (23)
P.Knowlesi (372) P.Ovale (1)

6. NIA BFMP 2012
• Observing 1-hour LTAT suggested by NIA.
• Emergency & Trauma samples contributed to 98% of total TAT forms received.
Feb-May
2012
June-Sept
2012
Oct-Dec
2012
Jan-May
2013
Forms 155 171 129 222
Feb-May
2012
June-Sept
2012
Oct-Dec
2012
Jan-May
2013
Mean LTAT
(mins)
44.3 43 46.49 45.74
41
42
43
44
45
46
47
Mean LTAT
(mins)

7. 96.77%
93.56%
92.18%
90.09%
Feb-May
2012
June-Sept
2012
Oct-Dec 2012 Jan-May
2013
Compliance rate for 1-hour LTAT
Compliance rate

8. Internal QC
 Internal QC for Giemsa staining
3% GIEMSA QUALITY CONTROL FOR BFMP STAINING
Date
Reagent Batch
Operator
QC Slide
Verification
Stock Buffer Working Buffer Background RBC
WBC
Nucleus Cytoplasm

9. Kes salah lapor
 1 case in 2012
Root-cause Analysis done
New microscope supplied by JKNS post-RCA
 2 cases in 2013

10. RCA of Incident : BFMP Epid
Week 36 Wrong Reporting
Team Members
1. Alexander Beemer Mijen
2. Siti Syartinah Shawkawi
3. Noel Ting Yong Yin
4. Saiful Ungo
5. Siti Syazwana Taip
6. Faiz Osen

11. Brief Summary of Incident A (Iban)
31st August 2012 (Friday, PH) sample Alexander Amit received by
oncall staff at 3pm. Oncall staff reported as negative.
1st September 2012 (Saturday, WE) Sero staff A counterchecked (AM
clearing) positive for P.Falciparum.
3rd September 2012 (Monday) Sero staff B countercheck (AM routine)
positive for P.Knowlesi, send slide to Vector Control Sibu.

12. Define the problem
(Using process diagram / sequence of
events)
Ref Date Time Location Event Description Key person(s)
involved
Comment/ Queries
31st August
2012 (PH)
1500hrs Lab sample Alexander Amit received by oncall staff at
3pm. Oncall staff reported as negative
Oncall MLT Was the sample
properly prepared
smear? (YES)
Was the smear
properly stained?
(YES)
1st September
2012
(Saturday)
AM
Clearing
Lab Sero staff A counterchecked (AM clearing) positive
for P.Falciparum.
MLT Organism clearly seen
on microscope? Can
make out for sure the
physical properties of
the said organism?
3rd
September
2012
AM
routine
Lab Sero Staff B countercheck (AM routine) positive for
P.Knowlesi, send slide to Vector Control Sibu
MLT Organism clearly seen
on microscope? Can
make out for sure the
physical properties of
the said organism?

13. Specimen
collection
Receive by
MLT, stained
View thru
microscope, res
ult released as
negative
Countercheck,
release as
positive for
P.falciparum
Routine
countercheck,
reported as
P.knowlesi
Send to
vector, vector
report as
P.falciparum
Smear
okay
Stain okay
Parasite
cannot be seen
Microscope not
clear, yellow light
not suitable for
viewing parasite
1st Sept 201231st August 2012
Identify contributory factors
(cause effect diagram/fishbone /5why)
3rd September 2012
Parasite can
be seen, can
confirm
positive, physio
logy not clear.
Parasite can
be seen, can
confirm
positive, physio
logy not clear.

14. Brief Summary of Incident B (Cina)
30th August 2012 (Thursday) – sample for Tan Kai Yung received by lab
staff, reported as P.Falciparum. Sent to Vector Control Sibu.
Vector Control reported as P.knowlesi, followed by State Vector as
P.knowlesi.

15. Define the problem
(Using process diagram / sequence of
events)
Ref Date Time Location Event Description Key person(s)
involved
Comment/ Queries
30th August
2012
(Thursday)
Routine Lab sample for Tan Kai Yung received by lab staff,
reported as P.Falciparum. Sent to Vector Control
Sibu
MLT Was the sample
properly prepared
smear? (YES)
Was the smear
properly stained?
(YES)
Organism clearly seen
on microscope? Can
make out for sure the
physical properties of
the said organism?
Vector Control reported as P.knowlesi, followed by
State Vector as P.knowlesi.
Vector
control staff,
State vector
liaison officer
N/A

16. Specimen
collection
Receive by
MLT, stained
View thru
microscope,
reported as
positive for
P.falciparum
Send to vector Vector Control
report as
P.knowlesi, State
vector as
P.Knowlesi
Smear
okay
Stain okay
Microscope not
clear, yellow light
not suitable for
viewing parasite
3rd Sept
2012
30th August 2012
Identify contributory factors
(cause effect diagram/fishbone /5why)
Parasite can be
seen, can confirm
positive, physiology
not clear.
4th Sept
2012

17. Plan of action
No Root cause Action Responsibility Date due
1
2
Microscope condition not
good, yellow light not
suitable for viewing
parasite morphology,
microscope lens not clear
Current microscope is
old, >10 years
To ask Faber to change the yellow
bulb into white bulb
To ask Faber to change lens
To replace current microscope with
new unit
Laboratory and
Faber
Laboratory
Management
Immediate
As soon as
possible

18. External QA Programme
 MKA Kota Kinabalu BFMP EQA Programme
Series 1 / 2013 participated
 Vektor Negeri EQA Programme
Sending of all positive BFMP slides to Vektor Sibu and Vektor
Negeri.

19. Staff Training
 Oncall staff BFMP training in 2012, 2013
 July 2013 – estimate to send mnimum 15 oncall staff to
Vektor Sibu for refresher course

20. Hospital Staff BFMP Smear
Training
 Done in 2012 and 2013
 Targets doctors and nurses responsible to prepare BFMP
slide smears
 Multiples sessions weekly, 10-15 participants per session
 Facilitated by Serology/Parasitology MLTs under supervision
by MLT Siti Syartinah Sharkawi

21. Thank you and have a
nice day!