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Root Cause Analysis : Peritoneal Fluid
1. RCA of Incident : Peritoneal
Fluid for Amylase
Team Members
1. Reginal Bantin (Pegawai Sains Kajikuman
C48 Menanggung)
2. Nurulamin Abu Bakar (Pegawai Sains
Biokimia C44)
3. Alexander Beemer (Pegawai Sains
Kajikuman C41)
4. Juanita Ling (Pegawai Sains Biokimia C41)
5. Sister Yong Suk Moi (Jururawat U32 KUP,
Surgical Department)
2. Brief Summary of Incident
23rd September 2012 – Peritoneal fluid for
amylase requested, sample sent same day at
6.30pm. Specimen received and signed by ab
staff RAF.
24th September 2012 – No result received by ICU
at 8am. ICU called lab at 9.30am and
12.40pm, MLT Sabinah informed result not
yet ready. Mr. Ashok called at 1.15pm –
Informed by Juanita that specimen only
received by biochem in the morning.
3. Define the problem
(Using process diagram / sequence of events)
Ref Date Time Location Event Description Key person(s)
involved
Comment/ Queries
23 Sept 2012 1830hrs ICU Dr. Mohd Zakri requested peritoneal fluid for amylase, sample sent
to lab. Sample received by MLT Rafidah.
Doctor , MLT Was the sample marked
urgent? Were there any
effort by the requesting
doctor to inform the lab
regarding the urgency of
the sample?
24 Sept 2012 0930hrs ICU ICU called lab regarding specimen result. Lab informed result
not ready. QC not in for analyzer.
Lab Staff Sample was not marked
as urgent, sample treated
as routine.
Analyzer QC having
problems.
1240hrs ICU ICU called lab regarding specimen result. MLT Sabinah
informed result not ready, lunch break.
Lab Staff
1315hrs ICU Mr Ashok called lab regarding specimen result. Science
Officer Juanita informed specimen was only received in the
morning, result given thru phone.
Lab Staff Were there sufficient
information given to doctor
regarding the cause of
sample delay? Is the test
stated in the Critical Tests
List for biochemistry lab?
4. Staff/MO
who collect?
Specimen
collection
PPK send to lab Received by MLT
on call
Biochem
received
Run Test Result Delay
Form didn't
notify
request as
urgent
Not in lab
policy
Logbook send in
ordinary way
No urgent noted
not indicated to
say urgent
Treat as
ordinary sample
Send to biochem
unit on 24th
sept
Specimen
clotted
Technical
Problem QC
Pleural fluid for
amylas is not in
Critical Test List.
*LTAT AMylase
is 45mins
24TH SEPTEMBER 201223RD SEPTEMBER 2012
Identify contributory factors
(cause effect diagram/fishbone /5why)
5. Plan of action
No Root cause Action Responsibility Date due
1
2
3
Non-urgent test was
requested during oncall
hours.
Equipment evaluation
Urgent Tests List needing
update
Requesting doctor to call up lab in-
charge to run non-urgent test during
oncall hours.
Equipment used to run amylase must
be evaluated again for QC consistency
Ward representatives and laboratory
in-charge to review Urgent Tests List
Requesting doctor
Laboratory in-
charge
Doctors and
Laboratory Officers
Immediate
Immediate
As soon as
possible