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Q Bulletin, Volume 1, No. 32 (Supplement 1), Jan - Dec 202412th National QA Convention, 8 %u2013 10 October 2024PP-05Reducing the Percentage of Delayed in Reporting Clinical Pharmacokinetic Service(CPS) Results in Hospital Tuanku Ampuan Najihah (HTAN), Negeri SembilanMuhamad Fauzanudin B1, Aslina A1, Ahmad Ridza AN1, Amril RA1, Safwanah R1, Noor Amalia B2,Nur Hazwani HS2, Nuraliyah D21 Pharmacy Department, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan.2 Pathology Department, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan.SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:Clinical Pharmacokinetics Service (CPS) is crucial in interpreting serum drug concentrations to optimise apatient's drug regimen. CPS specimens in Hospital Tuanku Ampuan Najihah (HTAN) were analysed byreferral facilities and interpreted by HTAN pharmacists. A verification study showed 72.8% of delayedCPS reporting (>24 hours) from April to June 2021. Delayed CPS reporting results in delays in treatmentand prolongs hospital stay. This study aimed to reduce the percentage of delayed CPS reporting.KEY MEASURES FOR IMPROVEMENT:The key indicator for improvement was the percentage of delayed CPS reporting results in HTAN. Thestandard is 0% based on the Consensus during the Drug Committee meeting in HTAN Bil.1.2021.PROCESS OF GATHERING INFORMATION:A quality improvement study involving all CPS requests for inpatients in HTAN from July 2021 toFebruary 2024 by using audit form. A questionnaire was used to identify contributing factors amonghealthcare providers.ANALYSIS AND INTERPRETATION:The verification study concluded 72.8% of delays in reporting CPS results. The contributing factorsincluded ineffective Standard Operating Procedures (SOP) (20.8%), incomplete CPS request forms(33%), inadequate knowledge among hospital staff (9%), and wrong blood sampling method (10%).STRATEGIES FOR CHANGE:Cycle 1 consisted of developing a CPS checklist, improving SOP for CPS referral and reporting,digitalization of the CPS reports, continuous CPS updates, and introduction of CPS sampling timestickers. In cycle 2, we presented CPS SOP video during new staff orientation, developed HTAN CPSGuideline Book and added asterisks on the important part of the CPS request form to prevent incompleteform.EFFECT OF CHANGE:The percentage of delayed CPS reporting results was reduced from 72.8% to 32.5% in cycle 1, thendecreased to 0% in cycle 2 and sustained in the sustainability phase. ABNA was narrowed down from72.8% to 0%. Mean duration of CPS reporting was successfully reduced from 28 hours to 6 hours.THE NEXT STEP:To expand the strategies to all hospitals in Negeri Sembilan.56 | Page