Authors (including presenting author) :
Ng WC(1), Mak YMK(1), Tsung WC(1), Tsang TK(1), Lam YMM(2)
Affiliation :
(1)Infirmary Unit, Shatin Cheshire Home,(2)Administration Department, Shatin Cheshire Home
Introduction :
Missing specimen is one of the risk in hospital, yet it may cause delayed diagnosis and treatment of patient. The consequence could sometimes be serious or even lethal. Being a hospital remote to laboratories, the process of collection, transportation of specimens is particularly important for Cheshire Home Shatin (SCH).
Objectives :
1. Nursing Team work with Central Supporting Service(CSS) to review the workflow and practice on collection of specimen
2. Revise the practice of specimen box or cabinet checking
3. Reeducate specimen registration tracking by nursing staff to identify the status of specimen
4. Enhance handover of awaiting results specimens
Methodology :
1. Multiple checkpoints were implemented to strengthen the proper delivery of specimens to laboratories.
a. After taking specimens:
• Types, numbers and patient names are recorded immediately on a specimen record.
b. During collection of specimens:
• Both ward and Central Supporting Service (CSS) staff perform a mandatory open box checking of specimen box to ensure no leftover specimens.
• Both staff check the information of specimen against the specimen record.
• The collection process is counter-checked and signed by both ward and CSS staff.
c. Before sending out to Cluster Transport:
• Ward clerk hands over all specimen to CSS staff and states clearly the total number of specimens and number of delivery box used.
• Ward in-charge checks the specimen box and record before handover to ensure no leftover specimens.
2. A few training sessions held by ward manager to ensure staff understand the specimen registration tracking method.
3. Handover of specimens
• Documentation in progress note and traces the status of specimen in CMS before handover. Laboratory staff would be contacted whenever in doubt
• All sent specimens will be handover to next shift until results are available.
4. Audit on Collection of Specimen to evaluate the process of specimen collection.
• On site audit was conducted for the staff including ward nurse, clerk and CSS staff.
• Samples was gathered by convenient sampling method on a session of specimen delivery.
• Audit would be performed yearly to ensure the collection process is in right track.
Result & Outcome :
All nurses, ward clerks and CSS team were compiled to the new workflow. Audit on specimen delivery has been conducted in October 2021. Compliance rate is 100%. No incidents of specimen delay or missing happened again.
The preventive measures have successfully to prevent the incidents of delayed delivery or missing specimen. The staff will continue these practices to make sure the patients have the appropriate treatment.
