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Core Lab April 2007 Staff Meeting Presentation. JCAHO Question. What quality improvement measures are collected and assessed in the Core Lab?. Turnaround time Completion of A.M. Phlebotomy Rounds Time to reach a Physician with a Critical Action Value. JCAHO Question.
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JCAHO Question What quality improvement measures are collected and assessed in the Core Lab? • Turnaround time • Completion of A.M. Phlebotomy Rounds • Time to reach a Physician with a Critical Action Value.
JCAHO Question What do you do to keep patients safe? • Require two patient identifiers. • Require physician to read back patient information. • Practice proper hand hygiene.
JCAHO Question Where do you report quality or safety concerns? • Your Lead or Supervisor • Pathology Administration • http://www.insidehopkinsmedicine.org/JHHScompliance/faqs.cfm • 1-877-WE-COMPLY • www.complaint@jcaho.org • 1-800-994-6610
Read Back • Customer Service – CAVs • Clinical Laboratory Scientists – CAVs • Critical Tests: -- O.R. ABG’s -- SUPER STATS -- ANYTHING YOU CHOOSE TO CALL TO A PROVIDER • Write it down, read back, and receive confirmation.
Unannounced JCAHO Surveys • Laboratory Surveyor: - Take to Supervisor - Escort to Pathology Administration • Hospital Surveyor - Accompanied with Hospital staff - Provide answers or documentation to the specific questions
Scenario 3/12 -- Delta MCV called to the floor and resulted. Delta Chemistries repeated and resulted. Patient typed and crossed A Pos (no previous history). 3/14 -- Patient transfused 2 units A Pos. Transfusion reaction 3 hours into the transfusion. Patient typed O Pos.
Patient Outcome • HIV-positive patient • Minimal reaction • Cleared 2 units of A Pos in 2 days • Slightly elevated bilirubin • Minimal organ damage • Most likely no long-term impact
Lessons Learned • Always transcribe patient’s name and history number from the wristband. • Never transcribe name and history number from the run sheet. • Label in the presence of the patient. • Phlebotomy survey. • Phlebotomy/Observations and In-Services.
Sample Investigation Policy Suspect specimen issue. Forward to Lead or Supervisor. Look at ALL Lab info for date & time. Decision to cancel. Notify all Labs. ~~~~~~~~~~~~~~~~~ When in doubt, bump up to faculty.
Outreach Potassium Study - March • Inspect all samples • Document all issues • Outcomes: 1 Improperly spun sample 1 Slightly elevated unexplained • Excellent detailed monitoring • Maintain “Heads Up Approach” to all Specimens
Lockers • You cannot “will” a locker to another employee! • Locker assignments: BLUE >30 hours BEIGE <30 hours
Electronic Devices • Cell Phones - Better • iPods - Not permitted - Safety Issue: Cords - Volume - Distraction
Weekend Callouts • Early Notification • FML Patterns • Weather Issues • Remember Your Peers
MPA Update • Processing: Monday, 4/23 • Trained Operators • Validation
MPA Update • Automation: Monday, May 21 • Flow Ratios • Instrument Outages • Monitor TATs
From the Beginning ….. until …..July 2011
Jennifer Taylor PhelpsHematology SupervisorFlow CytometryOncology HematologyMolecular Hematology • University of Pittsburgh graduate • Hematology/Chemistry Experience • QC Technologist • 11 Years JHH
ASCP WorkshopsTues. 5/1 thru Fri. 5/4 • 70 Attendees over One Week • Towson Sheraton • Roundtable Discussions to Follow
Lab WeekApril 22-28, 2007 Lunches, Breakfast Special CEs: 4/25 (Dr. Hruban) – 10 AM, 6:00 PM, & 7:30 PM 4/27 (Dr. Jackson) – 10:00 AM, Hurd Hall Fun, Games, Contests Pictures of Staff Fri. 4/27, Jeans Day for Ronald McDonald House ($1.00 min. donation) Manic Monday – April 23, 6:00 AM Fells Point (breakfast afterwards at Jimmy’s) 2nd Annual Medical Laboratory Expo to promote Medical Lab Profession Hippodrome, Sun. 4/29, 1:00-5:00 PM (see Chris H)
Lab Week Committee Members Renee Lazarony Leandra Soto Margo Echols Rhonda Cole Tora Ruffin Debbie Boblitz Polly Shukla Mark Swartz Christine Hostetter Kathy Kowalewski Lydia Nelson & Crew Willie Ferrer & Crew