[Histonet] JCAHO - Universal Protocol

Amy Self ASelf <@t> georgetownhospitalsystem.org
Mon Mar 23 13:10:35 CDT 2009

Dear Histonetters,

Is there anyone out there that follows the JCAHO - Universal
Protocol/Time Out procedure when the pathologist perform his/her own
FNA's?  We have a pathologist that will perform FNA's when asked and I
was told that when he performs these procedures that we need to be
following this universal protocol/time out procedure that is followed in
the OR for surgeries.  I have all the info. from the OR but to me the
procedure that they follow is just too in-depth for the palpable masses
that are aspirated for cytology.  So I am turning to you all for help.
I was just wondering what other facilities were doing about this.  Any
help would be appreciated.  Thanks in advance.      


Amy Self

Georgetown Hospital System


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