This document summarizes an incident report regarding delayed receiving of dengue NS1 specimens at a laboratory in Sarawak, Malaysia. Two specimens - for patients Galang Manga and Suling ak Uget - were requested on September 6th and 3rd respectively but results were not reported until September 24th and 27th. The investigation identified contributing factors such as insufficient laboratory staff, heavy workload causing delays in sample processing and packing for shipment, and almost all cases being requested urgently. Recommended actions included assigning additional staff, informing doctors of turnaround times, filtering urgent samples, automating data entry, and improving results reporting time.

1. RCA of Incident : Late Receiving
Specimen for Dengue NS1
Team Members
1. Reginal Bantin
2. Nurulamin b. Abu Bakar
3. Alexander Beemer Mijen
4. Mary Runita
Date: 8th October 2012
Location : Laboratory Admin
Time : 10.30am

2. Brief Summary of Incident
1) Galang Manga – requested 6th September
2012, received by Lab on 7th Sept, Sent to
SGH on 13th Sept (Thursday) by Poslaju (as
standard procedure). Sample received by
SGH on 19th Sept, Pathologist SGH reported
result on 24th Sept.
2) Suling ak Uget – requested 3rd Sept 2012,
received by Lab on 4th Sept, Sent to SGH on
13th Sept (Thursday) by Poslaju (as standard
procedure), received by SGH on 18th Sept,
Pathologist SGH reported on 27th Sept.

3. Define the problem
(Using process diagram / sequence of events)
Ref Date Time Location Event Description Key
person(s)
involved
Comment/ Queries
6th September
2012
ENT Clinic Dr. Lee Siew Ching (ENT Specialist) requested
HPE for Galang Manga
ENT
Specialist,
Attendant
7th September
2012
Laboratory MLT Mary received sample MLT Heavy workload
delaying sample
processing and
packing?
Urgent and non-
urgent cases?
13th September
2012
Laboratory Sample sent to SGH. MLT Is there a marked
delay in sample
sending according to
SOP?
Was there a problem
in meeting sample
packing TAT?
19th September
2012
Sarawak
General
Hospital
Sample received. SGH Staff
24th September
2012
Sarawak
General
Hospital
Pathologist reported results. SGH Staff Was there a delay in
receiving results?

4. Specimen
collection for
Galang Manga
Receive by
MLT
6th Sept 2012
Identify contributory factors
(cause effect diagram/fishbone /5why)
7th Sept 2012
(Friday)
13th Sept 2012
(Thursday)
19th Sept 2012 24th Sept 2012
Sample sent to
SGH
Sample
received by
SGH
Results reported by
Pathologist SGH
Specimen
collection
Insufficient Lab
staff, MLT Zaripah
is on maternity
leave
Manual entering
requests into
record book takes
time
1st sending in
September is on 3rd
Sept, patient
sample arrived on
4th Sept, missed
sending day.
Each request has 4 samples to
be packed for both Urgent and
non-urgent samples, heavy
packing workload
Delay in sending
samples
Requesting doctors
not familiar with
HPE sending
schedule
Long waiting time
to receive HPE
results
Entering data into
record book takes
time when heavy
workload
Almost all cases
were requested as
urgent

5. Define the problem
(Using process diagram / sequence of events)
Ref Date Time Location Event Description Key
person(s)
involved
Comment/ Queries
3rd September
2012
ENT Clinic Dr. Lee Siew Ching (ENT Specialist) requested
HPE for Suling ak Uget.
ENT
Specialist,
Attendant
4th September
2012
Laboratory MLT Mary received sample. MLT Heavy workload
delaying sample
processing and
packing?
Urgent and non-
urgent cases?
13th
September
2012
Laboratory Sample sent to SGH. MLT Is there a marked
delay in sample
sending according to
SOP?
Was there a problem
in meeting sample
packing TAT?
18th
September
2012
Sarawak
General
Hospital
Sample received. SGH Staff
27th
September
2012
Sarawak
General
Hospital
Pathologist reported results. SGH Staff Was there a delay in
receiving results?

6. 3rd Sept 2012
Identify contributory factors
(cause effect diagram/fishbone /5why)
4th Sept 2012
(Tuesday)
13th Sept 2012
(Thursday)
18th Sept 2012 27th Sept 2012
Specimen
collection for
Suling ak Uget
Receive by
MLT
Sample sent to
SGH
Sample
received by
SGH
Results reported by
Pathologist SGH
Specimen
collection
Insufficient Lab
staff, MLT Zaripah
is on maternity
leave
Manual entering
requests into
record book takes
time
1st sending in
September is on 3rd
Sept, patient
sample arrived on
4th Sept, missed
sending day.
Each request has 4 samples to
be packed for both Urgent and
non-urgent samples, heavy
packing workload
Delay in sending
samples
Requesting doctors
not familiar with
HPE sending
schedule
Long waiting time
to receive HPE
results
Entering data into
record book takes
time when heavy
workload
Almost all cases
were requested as
urgent

7. An immediate suggestion from Histopathologist
(SGH), Dr. Jacqueline Wong on 8th October
2012:
• All urgent samples must be sent immediately
• A Medical Officer must be stationed in
Histo/Cyto Laboratory to filter urgent/non-
urgent HPE samples to be sent to SGH

8. Plan of action
No Root cause Action Responsibility Date due
1
2
3
4
5
Shortage of staff, initial
additional covering staff
request was rejected by
Hospital Management
Clients (Ward/Clinics) not
familiar with HPE samples
sending schedule
Almost all cases were
requested as urgent
Manual entering data
takes too much time
Long period needed to
receive results
To assign floating MLT from other
laboratory unit to cover staff on
maternity leave
To inform requesting doctors about
HPE Turn-Around Time and sending
schedule (in memo)
To assign a Medical Officer in
Histo/Cyto to filter requests, urgent
requests shall be sent immediately
Creating Access database for ease in
entering data
To ask doctors to make HPE requests
through TelePrimary Care
Laboratory
Management
Laboratory
Management
Hospital
Management,
Hospital Director
Laboratory
Management
Requesting doctors
Immediate
Immediate
As soon as
possible
In progress
As soon as
possible

9. The End