Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Wong FCK(1), Pang KMC(2), Ng WM(2), Lam W(3), Chow JWL(4), Chan S(1), Koo EWF(1), Cheung NS(1), So S(1), Luk S(1), Leung W(1), Lee LW(1), Chung SL(1), Wong S(1), Tang L(1), Lee SL(2), Leung RYY(1)(2)
Affiliation :
Affiliations: (1) Hospital Pathology Service (2) Quality & Safety (3) Facility Management (4) Biomedical Equipment Maintenance, HKWC
Introduction :
Refrigerators and other temperature-controlled storage facilities in a laboratory operate round-the-clock. A temperature monitoring system ensures that their temperatures are within acceptable ranges at all times. Prompt intervention during instrument malfunction and temperature excursion is important to preserve the integrity of stored materials, including but not limited to patient specimens, reagents, quality control materials and blood products.
Objectives :
A full review and upgrade of central temperature monitoring systems (CTMS) have been performed in Pathology and Microbiology Laboratories of HKWC after a power outage incident in April 2023.
Methodology :
Site visits were performed in all pathology and microbiology laboratories in HKWC to check the existing configuration of temperature monitoring systems. Meetings with relevant stakeholders were held.
Result & Outcome :
9 laboratories (6 in QMH, one each in DKCH, GH and TWH) were involved. The coverage of CTMS installation was reviewed and found to be incomplete. All Laboratories agree to work towards full coverage with CTMS with the following minimum requirement: (1) Continuous monitoring of temperature; (2) An audible siren which is activated during temperature excursion; (3) A dual system in form of auto-dialer system to direct phone call to assigned contacts. (4) A computer and panel system with uninterruptible power supply (UPS) to ensure continuous power supply; (5) Activation of alarm in the event of low-battery condition or connection failure of temperature loggers. A risk-scoring system for such equipment with a scale of 0 -5 (5 being the highest risk) has been implemented and the corresponding risk level labelled on each equipment. 355 fridges, 29 incubators, 14 cold rooms, 12 laboratory areas and 2 warm rooms were involved, with 185 of them (45%) categorized as high risk (score = 5). Furthermore, each laboratory has established their own protocol regarding specific actions to be taken in the event of triggered CTMS alarms, e.g. relocation of stored items to unaffected refrigerators. All participating laboratories conducted drills to simulate an event of CTMS alarm triggered by temperature excursion and the results were satisfactory.
