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Root Cause Analysis, Rejection of Specimen by Referral Laboratory (Courier-related)

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Ze Wehrmacht Beemer
Ze Wehrmacht Beemer

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.

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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
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.
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.
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
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
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Root Cause Analysis, Rejection of Specimen by Referral Laboratory (Courier-related)

  • 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