Authors (including presenting author) :
Wong W(1), Pun K L(2), Mui M L(3), Wong K W (4), Leung K L(5), Lee T (6), Tsang KY (7), Cheung K L(1), CHAN M(2)
Affiliation :
(1)Quality and Safety Office, Tung Wah Eastern Hospital (2)Nursing Services Division, Tung Wah Eastern Hospital (3)Infection Control Team, Tung Wah Eastern Hospital (4)Department of Medicine and Rehabilitation, Tung Wah Eastern Hospital (5)Department of Ophthalmology, Tung Wah Eastern Hospital (6)Administrative Services Department, Tung Wah Eastern Hospital (7)Department of Pathology, Hong Kong East Cluster
Introduction :
In early 2021, a trend of delay in specimen transportation and missing specimens was detected. This could result in unnecessary repeat investigations and could potentially impact clinical treatment. With multiple steps in the transport process, the pathway is complex with multiple potential causes of error. In this study we focus on the pre-analytic phase of testing, which involves test ordering, specimen collection and handling, and specimen transport.
Objectives :
To propose possible strategies to reduce incidence of missing specimens using a plan-do-study-act cycle.
Methodology :
A working group was formed in May 2021 with representatives from all stakeholders to investigate and improve this vital service. Root cause analysis report of related incidents were reviewed. Two site visits with staff interview were conducted from clinical areas to local laboratory to evaluate existing improvement measures. Additional measures were also proposed to improve the process.
Result & Outcome :
From June to November 2021, we established two major areas of improvements - staff engagement and standard work instruction. Firstly, we observed that no staff identifier could be found on the specimen collection attendance sheet at the collection points, therefore customised name chops were made for the designated supporting staff for easy staff identification and enhance staff morale. Also on-site trainings and a standard work instruction were developed to reinforce proper infection control practices and standardise the process among different supporting staff and new staff. Positive feedback was received from supportive staff and they reported increase perception of organizational support for their work. We continue to monitor deviations in the process and make small process tweaks when any gaps are identified in the system. With the establishment of the work instruction, foreman supervisor could see the work in process, coach in real time if deviations are observed, and compile any weak points that require improvement. In the future effort will be put to explore the feasibility of adopting a specimen tracking solution to track specimens in real-time to improve specimen handling accuracy.
