QUALITY INDICATOR

PATHOLOGY DEPARTMENT

PRADNYASHIL S. RAUT

INCHARGE PATHOLOGY DEPT.

% OF CRITICAL ALERT
INFORMED
FORMULA = CRITICAL ALERT INFORMED *100
TOTAL CRITICAL ALERT

68/68*100

100 %
 RATE OF REDO’S
FORMULA = NO. OF REDO’S * 1000
NO. OF TEST PERFORMED

1/2471*1000
0.4
 ROOT CAUSE ANALYSIS

Heamatology – sample Sample taken from

not Cetral line in which
Mixed properly & run Iv fluids given to
(Technical error) patient

Re do`s

Biochemistry-Insufficient As requested by the

Sample in sample cup physician
(sampling error)
CORRECTIVE ACTION/PREVENTIVE
ACTION

Sr.No Corrective Action Taken Sr.N Preventive Action Taken

o
1 The provisional diagnosis did 1 Documentation of provisional
not match the test findings diagnosis.
2 Sample was run again. 2
 NO.OF REPORTING ERRORS

FORMULA = NO.OF REPORTING ERRORS *1000

NO. OF TEST PERFORMED

02/2471*1000
0.8
 ROOT CAUSE ANALYSIS

CLERICAL ERROR IN HAEMATOLOGY, WBC DLC &

WHILE TYPING PLATELETS COUNT HAS TO BE
EDITED AFTER LIS
THE FIGURES (LAB INFORMATION SYSTEM

REPORTIN
G
ERRORS

IN EMERGENCY,
PROCESSING IN SOME TEST,
OF SAMPLE IS DONE NUMERATOR &
URGENTLY DENOMINATOR VALUES
BEFORE ENTRY OF THE GET
PATIENT SO PRINTED REVERSED
LIS NOT DONE Eg.UACR
CORRECTIVE ACTION/PREVENTIVE
ACTION

Sr.No Corrective Action Taken Sr. Preventive Action Taken

No
1 Correction of print error 1 Asked the technician to be more
done . vigilant & careful while typing the
reports.
2 Report reprinted. 2 Every technician asked to check the
report before printing.
3 Technician made aware of 3 In case of hematology total DLC
the correct reports. should be 100 & correct platelets &
WBC count because CBC reports are
edited after this.
4 Counselling of the technician 4 Given warning to have action against
. him / her in case of repeated errors.
TURN AROUND TIME (TAT)
FORMULA = TOTAL TIME REQUIRED (MIN)
TOTAL TEST PERFORMED
TEST STANDARD (MIN) TAT(MIN)

CBC 30 30.9

KFT 35 35.07

LFT 45 39.59

URINE ROUTINE 30 28.44

COAGULATION 45 40.60
PROFILE
 GRAPH OF TAT OCT 2017
50

45

40

35

30

25 TAT
STANDARD
20

15

10

0
CBC KFT LFT URINE ROUTINE COAGULATION
PROFILE
 CRITICAL ALERT GRAPH OF OCT 2017
7

3 Total Critical Alert

Critical alert Informed

0
17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17
/ 20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20 /20
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
/1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
RATE OF REDO’S
NO. OF REPORTING ERRORS

160

140

120

100

80
Total no of tests
60 No. of Redo's
Reporting Error

40

20

0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17 0 17
1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2 1 /2
/1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1
01 03 05 07 09 11 13 15 17 19 21 23 25 27 29
THANK YOU