[Histonet] JACHO Compliance

[lpwenk <@t> sbcglobal.net]

The quote from 2005 JCAHO regulations for laboratories is as follows:
http://www.jcaho.org/accredited+organizations/laboratory+services/npsg/05_np
sg_lab.htm

"Use at least two patient identifiers (neither to be the patient's location)
whenever collecting laboratory samples or administering medications or blood
products, and use two identifiers to label sample collection containers in
the presence of the patient. Processes are established to maintain samples'
identity throughout the pre-analytical, analytical and post-analytical
processes."

Note that this is "whenever COLLECTING laboratory samples".

In two different JCAHO laboratory FAQ:
http://www.jcaho.org/accredited+organizations/laboratory+services/npsg/npsq_
faqs_2005.htm

"Does the requirement to label all specimens with two identifiers in the
presence of the patient apply to specimens collected by outside sources,
such as physician offices?
Yes. It is the intent of this goal to apply to all laboratory specimens.
Laboratories may have limited ability to oversee this portion of the
pre-analytical process, however, it is expected that all specimens arrive in
the laboratory with a minimum of two identifiers on them. (New 1/18/05)"

"Do the two sample identifiers have to be placed on every sample cup,
container or aliquot used during the analytical process?
No. When possible, laboratories are encouraged to label all aliquots with
the two sample identifiers. However, it is impractical to expect this for
all test systems due to space limitations on smaller sample cups and
containers. As long as the samples' identity is maintained throughout the
analytical process, this is acceptable. For example, identity is often
maintained through use of an accession number or assigned position numbers
on an analyzer. (New 1/18/05)"

My interpretation is that this ruling applies to the COLLECTION of specimens
in the OR, patients' rooms, doctors' offices. This ruling of needing two
identifiers does not apply to the specimen once it is in the lab.

However, there has to be a policy about accepting or rejecting specimens if
they do not have two identifiers (from same FAQ 2005 page):

"Does the Joint Commission require laboratories to reject specimens that
arrive in the laboratory without two identifiers?
No. While this may be an appropriate response for some situations, rejection
and recollection may not always be an acceptable option for samples that are
irretrievable, problematic or expensive to recollect (Pap smears), or when
rejection will produce a significant treatment delay.  The standards have
previously required laboratories to establish written guidelines for
specimen rejection. Such a policy may include a process for completing the
specimen identification when recollection is not a reasonable option. It
would be appropriate to include a cautionary statement on the laboratory
report indicating the specimen was received in the laboratory without
complete identification. (New 1/18/05)"

Hope this helps.

Peggy A. Wenk, HTL(ASCP)SLS
William Beaumont Hospital
Royal Oak, MI 48073


----- Original Message -----
From: "Scholz, Stephen J." <Stephen.J.Scholz <@t> osfhealthcare.org>
To: <Histonet <@t> lists.utsouthwestern.edu>
Sent: Friday, February 25, 2005 12:01 PM
Subject: [Histonet] JACHO Compliance


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
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