Root Cause Analysis of absurd results of Serum Potassium - Need for verification of vacuum tube quality
Objective: The study aims at performing root cause analysis of absurd results of serum potassium observed at biochemistry laboratory of new civil hospital Surat, Gujarat. 5-why technique is used to find root cause of the absurd results.
Methods: Fishbone diagrams for root cause analysis of absurd potassium results were developed. During analysis of each of possible causes results of July and August 2018 for serum potassium were exported from LIS. For each absurd report, serum potassium was analyzed in duplicate with QC samples. Calcium was also measured in such samples. Person collecting samples were interviewed for process of collection. Plain Vacuum tubes from supply department were checked for its potassium contamination.
Results and Conclusion: Calcium in serum with absurd potassium was very low, indicating EDTA contamination. K+ in some of the plain vacuum tube was unacceptably high. Fishbone diagrams are powerful technique for Root Cause Analysis, as it notes down even rarest cause in its fish bone. Such rare cause, as in current case of K+ contamination of plain vacuum tube during manufacturing, can be overlooked if such extensive cause listing is not done. K+ contamination of plain vacuum tube during manufacturing highlight need for developing protocols for routine testing of quality of vacuum tube before lot is put in to use
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