Objective To minimise the rates of avoidable error in the collection, processing and documentation of cerebrospinal fluid (CSF) samples acquired to investigate neurological emergencies.
Methods To identify common and avoidable sources of error, CSF samples sent for suspected subarachnoid haemorrhage or bacterial meningitis were considered retrospectively. A total of 30 CSF samples were sent between May and September 2018 from the Whipps Cross University Hospital Acute Admissions Unit. Based upon the sources of error identified, a series of interventions were devised to minimise future error. Error rates were reassessed between December 2018 and May 2019 after implementation of each intervention, over 2 ‘PDSA’ cycles.
Results Avoidable sample processing errors (e.g. under-filled bottles, inadequate requests) were reduced by a simple information sheet introduced to lumbar puncture (LP) packs. Deficiencies in documentation of LP procedures were overcome with the introduction of a structured computer template to be filled out after each procedure. Length of admission reduced from an average of 79 hours (pre-implementation) to 43 hours (after cycle 2).
Conclusions Three straightforward, ‘one-off’ and easily reproducible interventions led to considerably reduced rates of error in the processing and documentation of CSF samples for acute neurological emergencies.
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