A recent Joint Commission Resources consultative survey yielded two findings related to laboratory point-of-care: printing policies and procedures, and failure to label reagents and quality control with open and expiration dates.
It is against hospital policy to maintain printed policies and procedures from MediaLab (the Laboratory’s policy and procedure platform). Printing policies presents a risk to patients, our staff and the organization because printed policies are considered uncontrolled and not reliable sources of information. To ensure current policies and procedures are referenced, printed policies should not be stored in binders. All YNHH laboratories have implemented the MediaLab document control system, which staff should use to view Laboratory policies and procedures. To allow for continued access to policies and procedures for non-Laboratory personnel, read-only links were established.
Regulations require that all reagents and quality control are labeled with an open and expiration date to prevent the use of expired supplies, which can drastically impact test results. To ensure that all point-of-care testing supplies are appropriately labeled, each area must develop a system and assign responsibility.
Please round in your practice areas, discard any printed policies and label all unlabeled testing supplies. For more information, view the Safety Matters tip sheets in the Accreditation and Regulatory section of the employee intranet.
