An audit of requisition forms received at a histopathological laboratory: how compliant are submitting clinicians?

Abstract

Background: Studies have shown that most errors in laboratory medicine occur in the pre-analytic phase of the test cycle. Specimen registration, a component of the pre-analytic phase, is reliant on an accompanying correctly completed requisition form containing mandatory information as stipulated by the receiving laboratory.
Objective: This study was conducted to assess the completeness of requisition forms submitted to a histopathology laboratory.
Method: This retrospective study was conducted at the National Health Laboratory Services (NHLS) histopathology laboratory at the Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. Every tenth archived, original requisition form submitte between 1 January and 31 December 2019 was examined for completeness of information.
Results: In total, 1 603 cases were included in the cohort. The following information was supplied in more than 95% of the cases: patient name, gender, hospital number, ward, clinician name, medical practitioner number, clinical history and biopsy site. Of the remaining variables, date of birth was missing in 64.3%, clinician contact number in 88.3% and time of collection in 73.2% of the cases. Although it is not mandatory, patient stickers were not attached in most (94.6%) forms and 82% did not have a doctor’s stamp.
Discussion: While most details were completed on the selected requisition forms, clinicians’ contact numbers were absent on most requisition forms. These numbers should be provided in order to facilitate communication. Although doctors’ stamps and hospital-generated patient stickers were sparingly used, these could limit typographical registration errors which impact on traceability and linking of patient records. The requisition form should be viewed as a referral letter to the pathologist.
Conlusion: Clinicians and laboratory personnel should appreciate the importance of completing each mandatory field. Clinical meetings, electronic ordering systems and written guidelines may be useful to decrease some pre-analytic errors.