Root Cause Analysis, Late Receive Dengue NS1
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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.
Root Cause Analysis, Late Receive Dengue NS1
- 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