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| Towards
zero errors |
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| The
winning team from NUH. |
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The
launch of a cross-department project has led to
a drastic drop in the number of mismatched specimens
received by the Histopathology Department at the
National University Hospital (NUH).
Ms Match WIT, a multidisciplinary team comprising
staff from various departments, was formed to look
into the types of mismatched specimens. They found
that the Histopathology Department rejected them
where: |
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the
specimen and name/NRIC given did not tally
with the data in the request form, |
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the
patient’s name was not stated on the
specimen, |
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there
were two different patient names on a request
form, or |
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the
site of the specimen did not tally with the
information in the request form. |
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errors arose from a number of factors: |
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the
Computerised Patient Support System did not
automatically delete the data of the previous
patient when displaying the request form, |
| • |
wards/departments
were unaware of the large number of mismatched
cases, |
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staff
did not verify the patient’s particulars
on the label of the specimen with the information
in the request form before dispatching the
specimen, |
| • |
current
guidelines did not specify labelling requirements
such as the nature and site of the specimen,
and |
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there
were inadequate checks in place to prevent
errors from occurring. |
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A
series of changes were subsequently implemented.
They included improving the Computerised Patient
Support System, posting a checklist in all wards/departments,
raising awareness of the number of mismatched specimens,
and implementing revised procedures for handling
specimens.
The number of mismatched specimens has since dropped
significantly. This has translated to large savings
in manpower. The success of this project has contributed
towards the team from NUH winning the Gold Award
at the PS21 ExCEL Award Ceremony 2002 held in November. |
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| Text
adapted from an interview with Ms Match WIT, NUH
Next: Faster service at
CPF Board |
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