[Histonet] JACHO Compliance

[Scholz, Stephen J.]

Hello all;

We are about to have a JACHO inspection and a problem was brought to my attention.  It involves using two identifiers on all laboratory specimens.  

The below paragraph is from JCAHO FAQ web site for laboratory compliance with the National Patient Safety Goals.  This particular statement seems to answer the question about use of only one identifying number on a pathology or any lab specimen.  Please let me know your interpretation and how your laboratories comply to it.  Currently we have only the case number (hand written) on the blocks and only the case number (hand written) on the slides until after staining at which point there are printed labels put on them.  

Take note that this FAQ was updated in January, 2005.


FAQ-We use a label for the initial patient sample that contains only one unique identifier, a number, to identify laboratory specimens.  This unique identifier can be traced to multiple patient identifiers. Does this meet the intent of the goal?
ANS-No. The intent is to use two separate identifiers on the specimen label. Confidence in an accurate identification improves as the number of identifiers increases, depending upon their uniqueness.  A single identifier can be more easily misread, resulting in avoidable errors. Bar coding that includes two or more person-specific identifiers (not room number) will comply with this requirement. (New 1/18/05)



What are suggestions to my problem.


Stephen J. Scholz HT(ASCP)
Histology Coordinator
OSF St. Anthony Medical Center
Rockford IL

Phone: 815-395-5410
Fax: 815-395-5364