Page 73 - HA Convention 2016 [Abstracts (Day 1)]

Service Enhancement Presentations HOSPITAL AUTHORITY CONVENTION 2016

F4.7 Clinical Safety and Quality Service II 16:15 Room 421

New and Reinforcement Measures to Prevent Mislabeling and Mixing of Prenatal Specimens During Collection
and Transportation
Poon CF, Kwok SL, Ng SY, Shum KS, Mak SLA, Ma WLT, Leung KY
Obstetrics and Gynaecology Department, Queen Elizabeth Hospital, Hong Kong

Introduction

Mislabeling specimen is an adverse medical incident which can lead to severe potential medico-legal consequences.
Correct labeling of prenatal specimens (including amniotic fluid, chorionic villi and fetal blood) is one of the top clinical risk
management in our Maternal Fetal Medicine (MFM) Centre which has to manage more than 1,000 in-patient attendance in
the prenatal diagnostic and counselling clinic session and send out more than 300 prenatal samples for invasive diagnostic
testing per year. In response to the hospital’s alert, a quality improvement initiative was implemented.

Objectives

To prevent mislabeling and mixing of prenatal specimens during collection and transportation.

Methodology Tuesday, 3 May

Environmental scanning was carried out to identify any potential risk factors of mislabeling and mixing up of prenatal samples
during preparation, collection, handling, transportation to another hospital and recording. Workflow was redesigned, and
new guideline was formulated by the nurse-in-charge of the team and briefed to members in the team meeting to solicit their
opinions. It was then refined with consensus on standardising all the steps for distribution to team members, ward manager
and MFM team head/Chief of Service for endorsement before implementation in September 2015.

New measures included: (1) An information sample folder containing photos of infrequently used specimen containers and
forms was prepared. (2) The guideline and information sample folder were filed in the MFM protocol and kept in the procedure
room. (3) Attending doctors counterchecked patient’s name and identity card number at bedside immediately after sample
collection. (4) An audit on new guideline compliance was carried out. (5) The sample box was locked and placed in a secure
place of the nursing station before transportation to laboratory. (6) A new carrier bag with a digital lock was used (the porter
did not know the security code) during transportation of prenatal specimens to the prenatal laboratory of another hospital. (7)
Colleagues of the prenatal laboratory of another hospital who involved in receiving the sample box were informed of using the
new locked carrier bag and the security code of the digital lock.

Reinforcement measures included: (1) A new set of instrument must be used if the procedure was repeated. (2) Single use
of equipment to avoid cross-contamination of specimens. (3) Specimen container must be checked to ensure no previous
specimen before transferring the prenatal sample into it. (4) Site and source of specimen must be identified correctly for
multiple pregnancy. (5) Each specimen must be properly and correctly labeled before attending another patient. (6) Under
no circumstances should the specimens be handled by an unauthorised person. (7) The porter must sign the record book in
ward before taking the specimen box to the laboratory. (8) The signed return from the laboratory must be checked to confirm
receipt of specimens by laboratory staff.

Results

There were no incidents on mislabeling or mixing of prenatal specimens in our MFM centre in the past five years. Complete
compliance to the guideline was shown on clinical auditing. The verification procedures were welcomed by the involved
doctors and nurses. The porter and colleagues in the prenatal laboratory of another hospital were very satisfied with the use
of the new carrier bag. Implementation of the improvement measures served as a continuous process of risk management
and promoted positive safety culture in the department.

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