1) A sample for Primary Immunodeficiency Screening was received over a day late by the intended laboratory (AIRC IMR) due to issues in delivery by the courier service (Skynet). 2) The sample was sent by Serology Lab on April 23rd via Skynet but was not received by AIRC IMR until April 25th, resulting in the sample being rejected. 3) A root cause analysis identified that the sample was not properly labelled as urgent, causing it to be misdirected upon arrival at the main receiving counter instead of going directly to AIRC IMR. Actions were put in place to properly label urgent samples and communicate urgency.

1. RCA of Incident : Primary
Immunodeficiency Screening
Specimen Rejection by IMR
Team Members
1. Alexander Beemer Mijen
2. Siti Syartinah Sharkawi
3. Noel Ting Yong Yin
4. Saiful Ungo
5. Flora Denis
6. Siti Syazwana Taip
Date: 15 July 2013
Location : Serology Lab
Time : 10.00 am

2. Brief Summary of Incident
1) Sample for Primary Immunodeficiency
Screening was received from the ward on
23rd April 2013. Serology Lab sent the
package on the same day @ 5pm by SkyNet
to AIRC IMR. Sample was received by Kaunter
Utama Preanalitikal IMR on 24th April 2013
@9.30am. Sample was only received by AIRC
IMR on the 25th April 2013 @ 4.30pm.

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 Serology Lab Lab received specimen from PMW20, packaged
and sent to AIRC-IMR by Skynet at 5pm.
Lab staff
24th April 2013 9.30am Kaunter
Penerimaan
Preanalitikal
IMR
Kaunter Penerimaan Preanalitikal IMR received
specimen.
IMR staff Sample was not
directed to AIRC-IMR
25th April 2013 4.30pm Kaunter
Penerimaan
AIRC-IMR
Kaunter Penerimaan AIRC-IMR received
specimen. Specimen rejected due to delay.
AIRC-IMR
staff
Sample rejected due
to delay.

4. Specimen sent
to AIRC-IMR
with SkyNet
Receive by
Kaunter
Penerimaan
Preanalitikal
IMR
23rd April 2013
(Tuesday)
Identify contributory factors
(cause effect diagram/fishbone /5why)
24th April 2013
(Wednesday)
13th Sept 2012 (Thursday)
Received by
Kaunter
Penerimaan
AIRC-IMR
Sample
rejected due to
delay.
Sample was not
sent to AIRC-IMR
directly according
to address on
SkyNet sending
slip.
Specimen was not labelled as
“URGENT” on package before
delivery
Address
overlooked by
Skynet staff

5. Plan of action
No Root cause Action Responsibility Date due
1) Specimen was not
labelled as “URGENT”
on package before
delivery
All 24HRS specimen to be labelled as
“URGENT” on package.
To improve communication by calling
up client requiring them to double
confirm sample urgency before
sending.
To list down all known urgent
outsourced tests which require the
sample to arrive at destination within
24hrs.
Staff on
sending/packaging
duty
Staff on
sending/packaging
duty
Head of Unit
Serology
Immediate
Immediate
Immediate

6. The End