Authors (including presenting author) :
Fung MY (1), Fung SH(1), Wong LY(1)
Affiliation :
Cardiothoracic Surgical Department, Cardiac Operating Theatre, Queen Mary Hospital
Introduction :
Pathological laboratory procedure for intraoperative specimen analysis during operation plays an important role in performing rapid microscopic analysis of specimen and its further treatment in CTSD-OT. Multidisciplinary health care providers including nurses, portering staff, laboratory technicians work collaboratively with pathologists to collect and delivery specimen which poses a high risk of specimen delivery delay or even loss. There were two reported cases of specimen loss incident in Hospital authority in the year of 2017 and 2018. It is observable that the existing specimen delivery system is prone to specimen delivery delay or loss.
Objectives :
(1) To avoid specimen delay or loss of specimen in the specimen collection and delivery system by launching a series of interventions; (2) to institutionalize a safe specimen collection and delivery culture so as to increase awareness of the handling of specimen by different parties
Methodology :
An investigation group was formed in CTSD-OT from the year of 2016 onwards. Possible causes of delay and loss of specimen in CTSD-OT were analyzed and identified. Subsequent action plans were discussed. The following actions were implemented in two phases. An investigation group was formed in CTSD-OT from the year of 2016 onwards. Possible causes of delay and loss of specimen in CTSD-OT were analyzed and identified. Subsequent action plans were discussed. The following actions were implemented in two phases. Phase one started on the first quarter of 2016 targeting for increasing involved parties communication: (1) Effective team communication and timely bi-directional contact was substantially encouraged. (2)Intraoperative specimen collection and delivery workflow in CTSD-OT was modified. (3) A newly designed Label with delivery instruction must be attached on designated specimen carrier bag. Phase two started on first quarter of 2017 targeting for enriching patient intraoperative specimen recording: (4) Newly modified specimen record book for involved parties was designed according to the hospital policy. (5) Intraoperative specimen recording system in CTSD-OT was established for retrospective trace back. (6) Modified up-to-date specimen collection and delivery guideline was introduced to all staff.
Result & Outcome :
There has been no specimen delay or missing since the launching of this quality improvement programme. The parties involved hold positive attitude to the improvement. This improvement programme has eliminated the chances of specimen delay or loss and increased the staff awareness of specimen handling and delivery in CTSD-OT. The investigation group will further monitor and evaluate the effectiveness of the intervention. Electronic tracing system in specimen collection and delivery would be our next target for advanced improvement.
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