Laboratory of Pathology - Staff

Patient Safety Goals

Joint Commission National Patient Safety Goals

This section addresses the Laboratory of Pathology's (LP's) and the NIH Clinical Center's (CC's) adherence to elements of the JCAHO National Patient Safety Goals that relate to the Laboratory of Pathology. In an effort to assure the provision of consistent safe patient care in hospitals across the United States, the Joint Commission for the Accreditation of Healthcare Organizations has established patient safety goals that each facility must address in order to remain accredited. Below is a summary of each LP and CC policies and/or procedures that relate to relevant patient safety goals. Each Section Chief may establish additional procedures inline with the National Patient Safety Goals and CC policies, if necessary.

Laboratory of Pathology Patient Safety Goals

Goal 1 (Preanalytic): Ensure Correct Patient and Sample Identification.

1. At the time of specimen collection
2. At the time of analysis, including aliquots and secondary labeling
3. At the time of result delivery

Goal 2 (Analytic): Timely and Accurate Reporting of Pathology Results

1. Critical laboratory values reporting
2. Monitoring surgical pathology turnaround times
3. Intraoperative turnaround times
4. Post-mortem turnaround times
5. Molecular and Chromosome Pathology turnaround times
6. Evaluation of LP's Corrected Reports

LP Turnaround Times by Section

Due to LP's research mission and patient population, turnaround times may vary depending on several potential factors such as: extensive additional testing, coordination with the clinical team, requesting additional outside material or reports, and inter- and intra-departmental consultations. LP's target turnaround times (in work days) for at least 90% of cases from the specimen receipt date include:

• • Routine/Small Biopsies (SB): 2 days
  • Complex - Surgicals / Resections (SI): 5 days
  • Cytopathology (CG/CM): 5 days
  • Molecular Diagnosis (MD): 8 days 
  • Chromosome Pathology: 7 days
  • Flow Cytometry: 10 working days
  • Autopsy: 2 working days Preliminary Autopsy Diagnosis (PAD), Final (FAD) 60 working days
  • Submitted Service (SS, ST, SJ) are dependent on completeness of materials and reports received

Cases that exceed expected turnaround times are routinely communicated with the requesting/treating physician by the clinical fellow or attending pathologist.

Goal 3 (Preanalytic): Ensure Specimen Adequacy

1. Bone Marrow specimen adequacy
2. Molecular Diagnostics specimen adequacy
3. Chromosome Pathology specimen adequacy

Goal 4 (Postanalytic): Ensure the Identification, Communication, and Correction of Errors

1. Timeliness of identification of errors
2. Clear and timely communication and documentation of any corrected report to the treating clinician
3. Corrected / Revised reports are reviewed by QM Committee
4. Intraoperative Correlations

Goal 5 (Operational): Improve Integration and Coordination of Laboratory Patient Safety Role within the NIH Clinical Center:

1. Delayed Requisitions
2. Reporting Incidents that affect patient care to Clinical Center Staff (Safety Tracking and Reporting System)
3. LP's participation in CC Hospital Safety Committee

Goal 6 (Operational): Reduce the Risk of Health Care-Associated Infections by the Following Activities:

1. Reviewing WHO and CDC hand hygiene guidelines
2. Implementing best practices
3. Conducting periodic risk assessments
4. Ensuring participation of laboratory staff in infection control activities in the health care organization

NIH Clinical Center National Patient Safety Goals QM Data

Goal 1: Improve the accuracy of patient identification.

Use at least two patient identifiers when providing care, treatment, and services. Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.

MAS M03-1, Patient Identification requires the use of at least two patient identifiers (e.g., patient's name and date of birth) whenever taking blood samples or administering medications or blood products.

Goal 2: Improve the effectiveness of communication among caregivers.

Only those who are designated by the Clinical Center Medical Executive Committee, may accept and/or execute verbal orders consistent with his/her credentials, are of expertise, and position description. Verbal orders are discouraged unless necessary for immediate patient care reasons.  A nurse or an allied health professional has the authority not to accept a verbal order when in his/her judgment the order should be verified by the prescriber, or the patient should be seen by the prescriber, before the order is carried out.

MAS M04-1, Medical Orders in the Clinical Center, has been updated to include a requirement that the practitioner receiving a verbal order must "read-back" the complete order prior to entering the information into the CRIS.

Symbols, acronyms and abbreviations are not permitted in impressions, final diagnosis, or operation and procedure titles required on dictated medical reports.

Request for modification of the list should be forwarded to the Director of Medical Records.

MAS M94-18, Approved Symbols, Acronyms, and Abbreviations has been updated to include a list of UNACCEPTABLE abbreviations that are considered unsafe.

In addition, LP staff have a responsibility to ensure effective communication between pathologists and treating clinicians, nurses and allied health professionals.

Goal 4: Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.

The Surgical Administrative Committee and the MEC approved a policy M03-2: Correct-Site Identification for Surgical/Invasive Procedure that requires the use of a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available prior to a procedure. The policy also includes a requirement for the implementation of a process to mark the surgical site.

Goal 7: Reduce the risk of health care-acquired infections.

Comply with current Center for Disease Control (CDC) hand-hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.

• NIH Infection Control Resources
• NIH Hand Hygiene Resources

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