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Q Bulletin, Volume 1, No. 32 (Supplement 1), Jan - Dec 202412th National QA Convention, 8 %u2013 10 October 2024PP-18Improving Specimen Management via Hospital Information System (eHIS) inPathology Department, Hospital Sungai BulohStanley David P, Sharifah Khairul Atikah SK, Nor Shazwani AA, Zuhaira Hayati Y, Mas Ayu Izzati I,Norhasnida ZDepartment of Pathology, Hospital Sungai Buloh, Sungai Buloh, SelangorSELECTION OF OPPORTUNITIES FOR IMPROVEMENT:In Hospital Sungai Buloh, every specimen that has been ordered needs to be recorded as collected anddispatched in the Hospital Information System (eHIS). Specimens that were not recorded will beunrecognised and unable to be registered in the Laboratory Information System (LIS). This will cause adelay in the patient's care and result in unnecessary monetary and time wastage. The objective of thisQAP is to improve specimen management by reducing the percentage of unmanaged in-house specimensvia eHIS in Hospital Sungai Buloh.KEY MEASURES FOR IMPROVEMENT:The key indicator for improvement was measured using the percentage of unmanaged in-house specimensvia eHIS in Hospital Sungai Buloh. The standard to achieve is 0.3% of unmanaged specimens in referenceto the article from Annals of Laboratory Medicine.PROCESS OF GATHERING INFORMATION:A quality improvement study was conducted using convenience sampling of in-house specimens receivedby the laboratory in three consecutive cycles These data were collected via eHIS, LIS and a physicalrecord book. Contributing factors were identified via questionnaire, phone interview and ward/clinicvisits.ANALYSIS AND INTERPRETATION:Pre-remedial study showed 1.2% (n=59,916) of unmanaged specimens between January and February2022. The survey identified that poor practice among staff (69.6%), lack of awareness and knowledgeamong staff (15.3%), inadequate staff training (10.8%), and busy wards (3.5%) were the main causes.STRATEGIES FOR CHANGE:Multiple strategies were taken by creating a Whatsapp group between laboratory personnel and clinicalstaff, placing a reminder on all hospital desktops and pneumatic tubes as well as giving hospital CMEregarding unmanaged specimens.EFFECT OF CHANGE:The percentage was reduced from 1.2% to 0.29% in cycle 1, then improved to 0.28% in cycle 2 andsubsequently to 0.26% in cycle 3. Achievable Benefit Not Achieved was improved from 0.9% to -0.01%,-0.02 % and finally -0.04%.THE NEXT STEP:To share ideas to overcome similar problems to other hospitals through technical meetings.69 | Page