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
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
African-American Male, Age 50
Component
3/10/07
3/11/07
3/12/07
3/13/07
3/14/07
SODIUM
134
136
139
134
33
POTASSIUM
3.8 *
3.5 *
4.4 *
3.1 *
3.2 *
CHLORIDE
103
105
104
104
102
SUN
13
9
33 *
12 *
7
170 *
105 *
122 *
102 *
96 *
CREATININE
0.8
0.8
1.1
0.9
0.8
CALCIUM
7.9
7.9
8.8
7.1 *
7.4
TOTAL PROTEIN
6.1
5.8
6.4
5.6
5.4
ALBUMIN
2.5
2.2
3.3 *
2.4 *
2.2
BILIRUBIN
0.3
0.3
1.4 *
0.3 *
0.4 *
ALT
14
15
81
12 *
16
AST
54
56
40
71 *
69
ALK / PHOS
575*
484 *
65 *
456 *
439
CO2
18 *
23
26
23
23
ANION GAP
17
12
13
10
11
SUN / CREAT
16
11
30*
13 *
9
AST / ALT
3.9
3.7
0.5 *
5.9 *
4.3
GLUCOSE
African-American Male, Age 50
3/10/07
3/11/07
3/12/07
3/13/07
3/14/07
WBC
3860
4420
2130 * A
5270
3940 *
RBC
3.25
2.64
2.56 A
2.54
2.49
HgB
9.1
7.5
8.8 A
7.2
7.2
PCV
29.6
24.1
28.1 a
23.1
22.8
MCV
91.1
91.3
109.8 * A
90.9 *
91.6
MCH
28.0
28.4
34.4 A
28.3
28.9
MCH C
30.7
31.1
31.3 A
31.2
31.6
RBC DISTR
15.4
15.4
19.2
15.4
15.2
PLATELET
56
66
117 A
81
94
NRBC NO.
0
0
50 A
0
20
Component
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 Phelps
Hematology Supervisor
Flow Cytometry
Oncology Hematology
Molecular Hematology
• University of
Pittsburgh graduate
• Hematology/Chemistr
y Experience
• QC Technologist
• 11 Years JHH
ASCP Workshops
Tues. 5/1 thru Fri. 5/4
 70 Attendees over One Week
 Towson Sheraton
 Roundtable Discussions to Follow
Lab Week
April 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