[MT-L] Question CAP requirement GEN.40530 Specimen Tracking Phase I
Timothy...@sshosp.org
How are other MT sites meeting the below requirement??
GEN.40530 Specimen Tracking Phase I
For specimens submitted to the laboratory from remote sites, there is a documented tracking
system to ensure that all specimens are actually received.
NOTE: Documentation should include time of dispatch and receipt, as well as condition of specimens
upon receipt. An example of an acceptable tracking system is submission of a packing list (prepared
by the client or courier) with each batch of client specimens, which may be checked against the
specimens received by the laboratory. Some laboratory tests (e.g. coagulation assays) have
limitations on time and temperature conditions between collection and analysis. This requirement
applies to couriers/transportation systems that are part of the laboratory organization, not to outside
courier systems.
Evidence of Compliance:
✓ Specimen shipping/transport logs AND
✓ Records of follow up for specimens not received
For our off sites which utilize our Meditech, I plan on setting up a "site batch" report that they can print with all the specimens they are sending. On the report will be a spot for pick up time, drop off time...etc.
How are sites handling pick ups at non-affiliated Dr offices which don't use MT? These usually come to us on paper req's with the specimen.
Any info is greatly appreciated.
Thanks
Timothy J. Rogers
Clinical Applications Specialist II
Information Systems
Tel: (781) 624-4311
Fax: (781) 624-8885
Bpr: (781) 624-8123 **4787**
Bosworth, Kathryn
We utilize the site batch routines for our off-site phlebotomy draw stations and also for our reference lab specimens. We are MAGIC 5.64.
Kathryn Bosworth BSMT(ASCP)
LIS Coordinator
Columbia Memorial Hospital
71 Prospect Ave
Hudson, NY 12534
Office: (518) 828-8129
Mobile: (518) 653-8466
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Birkenholz, Karen
To: medit...@mtusers.com
Subject: [MT-L] Question CAP requirement GEN.40530 Specimen Tracking Phase I
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Freeman, Gale
The places keep logs of what they send us and we process the Protime’s first when they come in so they meet the time frame for collection to process. We have worked on that for years to get it so it is appropriate. We also have the courier buckets with ice packs, etc… to keep cold. We have never been cited for this, but we are inspected by NYSDOH and not CAP. mkk
Hope this helps.
Gale
From:
meditech-...@mtusers.com [mailto:meditech-...@mtusers.com] On
Behalf Of Timothy...@sshosp.org
Sent: Thursday, May 24, 2012
8:07 AM
To: medit...@mtusers.com
Furbush,Debra
We have been CAP for years and were originally keeping this information in a MS database which required information to be entered again specific to the patient. As we worked on our ISO accreditation 2-3 years ago, we came up with a way to record this in Meditech and then use NPR to extract it. We are magic 5.64 PP14. We created a LAB PAT CDS screen loading in all the queries we needed to record. Once we decided what we needed on this screen, we then duplicated them several times in case the same account was used for multiple days/draws. It allows us to record what specimens/containers received, date and time of pickup, date and time of delivery to lab, lab and origin tracking numbers, whether it was spun or unspun, problems with the specimen, and paperwork issues. There are several NPR reports that then tabulate data from this screen such as any specimen that had certain issues, or had incorrect paperwork accompanying it.
Hope this helps,
Wood, Carrie L
Melissa Wyant
Pharmacy Application Analyst, IS
Holyoke Medical Center
Phone: 413-534-2842
>>> "Wood, Carrie L" <CW...@PCHONLINE.ORG> 5/24/2012 3:05 PM >>>
Chris Dickerman
If you are C/S 5.64 or 5.65 there is a custom from Meditech to block these until verified by the pharmacy.
Chris
Leona Bizier
eMar access.
Leona Bizier
Pharmacy Analyst
Sturdy Memorial Hospital Inc.
Attleboro MA 02703
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Chicoine, Doris J
To: Furbush,Debra; Freeman, Gale; Timothy...@sshosp.org; medit...@mtusers.com
Subject: [MT-L] Keeping unverified meds from the EMAR
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Wood, Carrie L
From: Melissa Wyant [mailto:Wyant_...@holyokehealth.com]
Sent: Thursday, May 24, 2012 3:51 PM
To: Debra Furbush; medit...@mtusers.com; Wood, Carrie L; Gale Freeman; Timothy...@sshosp.org
Subject: Re: [MT-L] Keeping unverified meds from the EMAR
Jeff Lee
We’re having a good discussion about this workflow here right now. I am curious how well this is working for those who are suppressing unverified orders on eMAR. My concern is in the stat/urgent scenario. I’m assuming that the pharmacist is verifying the order(s). Does this lead to situations where the nursing staff are unaware of urgent orders that pharmacy can not yet process for any number of reasons? Does this lead at times to unnecessary patient delays?
We are considering to allow unverified orders (including pending orders to let nurses know the progress on unresolved/pending orders) to show on the eMAR, but including an eMAR rule to block (or warn) of the unverified status. I’m concerned with suppressing the knowledge of a POM order from nurses, assuming pharmacy can respond to all stat/urgent orders 24x7 to meet the patient needs. It seems to me that if pharmacy could do this in the pre-CPOE world, why did we ever allow any medications be overrrideable from dispensing machines?
Jeff
Melissa Wyant
Tim McCombs
Do you want it off because nursing is giving these to the patient anyway, without documenting it? (We prevent administration until the order is Verified and Acknowledged.) Or is there something else I am missing?
Dan Hawrot
Hello
We are Magic 5.64. The unverified orders here do not flow to the eMAR. However, the
unverified orders, which includes the pending orders, can be seen via the status board.
We are looking into a possible custom to just have pending orders appear on the eMAR.
Dan Hawrot, RPh
Trinity West
Steubenville, Ohio
740-283-7587
Jeff Lee
That is pretty much in line with the decision we just made to:
1) allow RNs only to acknowledge orders
2) display unverified meds on eMAR for RNs, but not LPNs
3) block administration of unverifieds on eMAR using a rule, with the exception of those that have a STAT direction.
One of our primary concerns was to have a system where “someone” could use the eMAR/BMV system to administer urgent orders (prior to verification); else we felt we would be encouraging the practice of giving meds outside of the BMV process and late documenting.
Thanks for the comments.
Jeff
From: Ray Fernandez [mailto:rfern...@dearbornadvisors.com]
Sent: Thursday, May 31, 2012 11:11 AM
To: Jeff Lee; Wood, Carrie L; Melissa Wyant; Debra Furbush; medit...@mtusers.com; Gale Freeman; Timothy...@sshosp.org
Subject: RE: [MT-L] Keeping unverified meds from the EMAR
I encourage displaying unverified orders on the eMAR so the nurses are t least aware of the medication. However, I also recommend not allowing administration/documentation of unverified meds. This can be accomplished by use of a Rule (pre- 6.0 at least) that displays a warning to the user and will not allow administration on a med if it is unverified.
In the instances of a STAT order, if necessary the nurse can override the med from a dispensing machine, generate the one-time order for documentation purposes, and when pharmacy verifies the order they can link it to the override to prevent duplicate orders / double admins.
CONFIDENTIALITY NOTICE: This message, including attachments, is the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of this original email message.
Ray Fernandez
I encourage displaying unverified orders on the eMAR so the nurses are t least aware of the medication. However, I also recommend not allowing administration/documentation of unverified meds. This can be accomplished by use of a Rule (pre- 6.0 at least) that displays a warning to the user and will not allow administration on a med if it is unverified.
In the instances of a STAT order, if necessary the nurse can override the med from a dispensing machine, generate the one-time order for documentation purposes, and when pharmacy verifies the order they can link it to the override to prevent duplicate orders / double admins.
From: meditech-...@mtusers.com [mailto:meditech-...@mtusers.com] On Behalf Of Jeff Lee
Sent: Tuesday, May 29, 2012 12:40 PM