[Histonet] RE: Histonet Digest, Vol 64, Issue 42 JCAHO - Universal Protocol (Amy Self)

[Lecorchick, William]

We do 3 to 4 FNA's on a daily basis and no matter the site thyroid, liver ..Etc we go through the time out procedure every time, yes it may a little bit overkill for a palpable mass or using ultrasound guidance but none the less you must do it just like labeling the lido cane when it is the only syringe on the tray.
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Message: 3
Date: Mon, 23 Mar 2009 14:10:35 -0400
From: "Amy Self" <ASelf <@t> georgetownhospitalsystem.org>
Subject: [Histonet] JCAHO - Universal Protocol
To: <histonet <@t> lists.utsouthwestern.edu>
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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