Authors (including presenting author) :
CHIU PL(1), LAM YM(1), TAM KHB(1), WONG CY(1), LEUNG WLO(1), WONG WH(1), LEE WH(1), LEUNG HC(1), CHAN YW(1), LEUNG PMQ(1)
Affiliation :
(1)Nursing Services Division, New Territories West Cluster
Introduction :
This is the first establishment of a structured clinical skills audit framework in Central Phlebotomy Team across three hospitals (TMH, POH, TSWH) in New Territories West Cluster. The initiative addresses the need for a robust and systematic approach to evaluate and maintain phlebotomy service standards through regular assessment cycles. A controlled document was established to standardise the audit process and requirements.
Objectives :
The newly established framework aims to implement a standardised approach for enhancing awareness of clinical standards, ensuring practice compliance, evaluating performance systematically, and identifying service improvement opportunities. This structured approach provides a foundation for consistent quality monitoring in phlebotomy services.
Methodology :
The framework introduces a comprehensive audit cycle covering five core clinical skills: Blood Taking in General and Isolation Settings, Blood Culture, IV Cannulation, and Specimen Collection. The 18-month implementation cycle is divided into five phases, with each phase incorporating pre-audit preparation, data collection, and post-audit analysis. Detailed explanatory notes were developed for each audit criterion to ensure clear understanding and consistent interpretation between auditors and auditees. Qualified auditors utilize standardised audit forms and these explanatory notes to ensure consistent evaluation.
Result & Outcome :
The inaugural 18-month implementation cycle demonstrated outstanding outcomes, with weighted compliance rates of 99.62-99.84% across all audited skills, indicating exemplary adherence to established standards. Longitudinal analysis revealed a sustained reduction in phlebotomy-related incidents (including specimen mislabelling/misuse and patient misidentification), decreasing from a baseline of 11 cases to 8 and 7 cases in subsequent years. Concurrently, phlebotomists proactively prevented errors by detecting incorrect patient identifications on referrals, with cases increasing significantly from 1 to 6 in the first year. This pioneering framework represents the cluster's first structured approach to phlebotomy service quality evaluation, establishing robust protocols for systematic skills assessment, real-time feedback mechanisms, and standardised performance monitoring. These achievements create a strong foundation for continuous quality enhancement and establish new benchmarks for phlebotomy service excellence across departments in cluster hospitals.
