Assessment of incompleteness in microbiology laboratory request forms at a University Hospital in Sri Lanka: Implications for preanalytical quality improvement

Introduction: A laboratory request form is an important mode of communication between the clinician and the laboratory. Accurate information provided in a microbiology request form is useful in identifying errors in the preanalytical stage, making decisions in the analytical stage, and interpreting results in the post-analytical stage of specimen processing. This study aims to describe the degree of incompleteness of microbiology laboratory requests at a university hospital in Sri Lanka.
Methods: All urine and blood culture request forms received by the microbiology laboratory during a 6-month period were studied. Each request was assessed for the completeness of the information requested on the form.
Results: Of 2087 request forms, none were filled completely. The patient’s name was present in all request forms, while the age and gender were absent in 37 (1.8%) and 380 (18.2%) respectively. The location of the patient was not given in 380 (18.2%). Clinical information of the patient with a short clinical history and details of antibiotics were missing in 840 (40.2%) and in 1665 (79.7%) respectively. A high rate of incompleteness was seen in specimen details such as the date (1479, 70.8%) and time of specimen collection (2011, 96.3%). The clinician’s name and designation were lacking in 1457 (69.8%) and 1110 (53.1%) respectively, while the signature was not available only in a few, 131 (6.3%,).
Conclusion: Manual completion of microbiology laboratory request forms was not satisfactory. Details mainly lacking were related to specimen collection, clinical details, and clinician details. Poor documentation on request forms may lead to incorrect reporting and/or interpretation of results, and delays in reporting. Implementation of an electronic request form with mandatory components through an Electronic Medical Record (EMR) system incorporated into a Laboratory Information Management System (LIMS) is an alternative that would correct these gaps, minimise errors, and enhance the quality of reporting in microbiology diagnostic laboratories.