Do Clinicians Provide the Laboratory with Sufficient Information? an Audit of Microbiology Laboratory Requisition Form Completion

Background: Pre-analytical errors contribute significantly to the reduced quality of laboratory results and may adversely impact patient management. Appropriate completion of the laboratory requistion form (LRF) by clinical staff is an important element of the pre-analytical phase. As a quality improvement initiative, a sample of LRFs submitted to the Charlotte Maxeke Johannesburg Academic Hospital Microbiology Laboratory was audited. Methods: A pilot study reviewing LRFs for the period 1–18 September 2020 for tissue, pus, sterile site fluids and pus swab specimen types was undertaken. An assessment of the completeness and correctness of information in LRFs was performed. Parameters were assigned to four quality indicator (QI) groups, namely patient identifiers, clinician identifiers, test request and clinical details. Results: An audit of completed LRFs for 172 specimens was performed, suggesting wide variability in the completion of parameters. Clinical details (description of the site of specimen collection, diagnosis and medication) were the most poorly completed components. The contact number of the requesting healthcare worker (HCW) was missing in 91% of requests. The most consistently completed and reliable QI was patient’s details. Other mandatory parameters, including the HCW’s name and practice number, were completed in 95% and 99% of LRFs, respectively. Conclusions: The inconsistent completion of key parameters in the LRF is of concern, and larger studies are warranted to determine the broader implications of our findings. Strategies to improve the completion of microbiology LRFs in this setting include educating the medical staff and students, expanding mandatory fields in the LRF and implementing an electronic requisition system.