2024 analysis

HQE Specimen Rejection Analysis: Chemical Pathology 2024

1. Overall Rejection Rates:

Inpatient specimen rejection rates were consistently higher than those for outpatient and outstation samples across all four quarters:

1. Jan-Mar: Inpatient 2.00% vs Outpatient/Outstation 0.60%

2. Apr-Jun: Inpatient 1.89% vs Outpatient/Outstation 0.48%

3. Jul-Sep: Inpatient 2.49% vs Outpatient/Outstation 0.52%

4. Oct-Dec: Inpatient 2.35% vs Outpatient/Outstation 0.78%

2. Top Reasons for Specimen Rejection (Overall):

1. Repeated Test Requests

   1. The leading cause of specimen rejection in all quarters and for both inpatient and outpatient categories.

   2. Quarterly Rejected Samples Due to Repeats:

      1. Jan–Mar: 2,921

      2. Apr–Jun: 2,734

      3. Jul–Sep: 3,155

      4. Oct–Dec: 3,818

2. Blood Clotted

   1. Particularly prevalent in inpatient samples and associated with blood gas tests in heparinized syringes.

   2. Corrective Action: Improve sampling technique:

      1. Proper heparinization

      2. Immediate mixing

      3. Transport in ice-water slurry within 30 minutes) 

3. Test Not Indicated

   1. Regular contributor to rejections.

      1. Jan–Mar: 1,012 samples

      2. Apr–Jun: 1,161 samples

      3. Jul–Sep: 845 samples

      4. Oct–Dec: 541 samples

   2. Corrective Action: Screen special biochemistry requests for appropriateness based on clinical history. Ensure complete documentation and specialist endorsement for referred tests.

4. Hemolysed Samples

   1. Prominent in outpatient settings.

   2. Notably high in Apr–Jun and Jul–Sep.

   3. Corrective Action: Improve phlebotomy practices:

      1. Correct needle gauge

      2. Allow alcohol to dry

      3. Minimize tourniquet time

      4. Avoid forceful aspiration/transfer

      5. Adequate tube filling and timely transport

5. No Sample Received

   1. Affects mainly outpatient samples (e.g., FBS/RBS).

   2. Apr–Jun: 438 cases

   3. Corrective Action: Reinforce protocols for:

      1. Proper tube use (e.g., fluoride oxalate)

      2. Plasma separation for outstation

      3. Labeling shared samples appropriately

6. Other Notable Causes

   1. Wrong Container/Fixative: Persistent issue.

      1. Action: Refer to Lab Handbook for proper tube selection.

   2. Decomposed/Degenerated Specimens: Especially for outpatients in Q4.

   3. Labeling/Form Issues, Leaking Tubes, Unsatisfactory Slides, Improper Volumes.

3. Top Contributing Locations:

1. 1. General Medical Wards (GM1–GM4): High rates of clotted samples and repeats.

   2. Emergency Department – Yellow Zone: Often involved in hemolyzed samples.

   3. Acute Internal Medical Ward (AIM): Recurrent high rejection rates.

   4. Other units with significant contributions: HAEW (Haematology Ward), SHDU, HD, Resus, FOW, RZ.

4. Corrective Actions:

1. Repeated Tests: Enforce testing intervals; require justification for early repeats.

2. Clotted Samples: Enhance blood gas collection techniques and prompt transport

3. Test Not Indicated: Screen special test requests; ensure adequate clinical info and documentation

4. Hemolysed Samples: Improve venipuncture technique and transport procedures

5. No Sample Received: Emphasize proper sample handling, especially for FBS/RBS and outstation samples

6. Wrong Container: Train staff using Lab Handbook references

Conclusion:

From January to December 2024, repeated test requests remain the predominant cause of specimen rejection, followed by clotted blood samples, test not indicated, hemolysis, and no sample received. Inpatient settings face greater challenges, with certain wards and departments disproportionately contributing to rejection rates.

Addressing these persistent issues through targeted training, process improvement, and strict adherence to established protocols is vital for reducing specimen rejection and ensuring efficient, accurate laboratory services.