August 12, 2005

JCAHO to survey MGH laboratory services

The MGH has received official notice that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be conducting a survey of the hospital's laboratory services Sept. 19 through Oct. 3. This 11-day visit will be conducted by one surveyor who will inspect the Pathology Service and any area of the hospital that performs lab tests.

Employees who are preparing for this lab inspection should focus their efforts on areas and topics such as verification of patient identification, reference ranges and procedures for point-of-care testing, tissue banking, phlebotomy and transfusion procedures.

One topic that MGH staff members have been focusing on in particular during the lab survey preparations is the appropriate reporting of critical lab test results. Delays or errors in communicating critical test results have been widely recognized as a serious patient safety risk. Critical test results are those that, if left untreated, could be life threatening or place a patient at serious risk.

To address this potentially serious problem, JCAHO developed a specific patient safety goal that focuses on effective communication among caregivers. Though the communication safety goal itself is not new, an important change has been made. Prior to 2003, the person who received a critical result over the phone could simply "repeat back" the information. Today, JCAHO requires the person receiving a critical result to write down the complete result and then read it back. Laboratory staff will ask the person receiving the information to read back the results. The critical test result should be written in an appropriate location — such as the flow sheet, progress note or designated book — and the appropriate clinician should be informed that the test result has been received.

The Laboratory Results: Guidelines for Retrieving and Reporting policy in the Clinical Policy and Procedure Manual describes the MGH process in further detail. Also, a list of critical values is available on the MGH Laboratory Handbook website at http://mghlabtest.partners.org/CriticalValues.htm.

For more information about the upcoming lab survey and the 2006 hospital survey, visit the hospital's JCAHO website at www2.massgeneral.org/jcaho.