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Compliance & Safety

Compliance & Safety, Education & Training

Zero Tolerance Specimen Labeling

All specimens submitted to Spectrum Health Laboratory for testing must be appropriately labeled to assure positive identification and optimum integrity of specimens. In accordance with standards issued by The Joint Commission, at least 2 patient identifiers should be used when providing care or treatment of services (National Patient Safety Goal, NSPG.01.01.01). If 2 patient identifiers are not used on the specimen, the specimen will be rejected, the order will be cancelled and a request for recollection will be made. This includes Gyn Cytology (i.e. Pap) specimens.

What are acceptable Patient Identifiers?

  • Patient Full Name
  • Date of Birth
  • Spectrum Health Medical Record Number (MRN)

 

Compliance & Safety, Referral/Sendouts

Warning: Patients being treated with Fulvestrant (Faslodex)

The manufacturer of the Estradiol reagent has reported a cross reactivity between their Estradiol assay and Fulvestrant causing a falsely elevated level of estradiol. Patients being treated with Fulvestrant should have their Estradiol levels monitored with the following test: Estradiol by LCMS.

Questions or inquiries may be direct to Dr. David Alter in the Pathology Department.

Compliance & Safety, Cytology, Education & Training

Appropriate Labeling of Specimens

Safety of our patient and quality of care are of utmost importance. For this reason we require specimens sent to the Spectrum Health Cytology Laboratory be labeled with at least two patient identifiers, (i.e., patient name, birth date and MRN.) We will no longer return to the collection site, unlabeled, mislabeled specimens lacking two patient identifiers or specimen containers with multiple different patient labels. These specimens will be discarded and repeat collection will be necessary.

Procedures to verify correct labeling of patient specimens at the time of collection are recommended.   Specimen containers should not be pre-labeled. Variation of the “time-out” procedure used in the hospital and surgical center setting is an excellent way of confirming that the specimen is correctly labeled. This can easily be achieved by having the patient verify his or her name and birth date, by reading the label placed on the specimen container at the time the specimen is collected. This “time out” should occur before the specimen leaves the examination or treatment room.

It is our mission to provide the best and safest care we can to our patients. We know that physicians and other practitioners are required to see patients more efficiently and at times with less than adequate time allowed. Following a “time out” procedure and not pre-labeling specimen containers will prevent errors that may lead to diagnoses being assigned to wrong patients, hence, unnecessary procedures and lack of follow-up for the appropriate patient.

Advanced Technology Laboratory, Compliance & Safety, Cytogenetics, Flow Cytometry, General Information, Molecular Diagnostics, Referral/Sendouts

Informed Consent Requirement

A1AT Proteotype S/Z and Alpha Globin Gene Analysis genetic tests now require informed consent along with those genetic tests that already require it (see below).

Spectrum Health Information Services has added an Ask at Order Entry question (AOE) “Has signed informed consent been obtained from the patient: Yes/No” to these tests. If the answer to this question is no, testing will either not be drawn (outpatient) or cancelled until informed consent is obtained by the ordering provider. Link to Informed Consent Form.

Tests which require informed consent:

A1AT Proteotype S/Z FISH for Trisomy 21
Alpha Globin Gene Analysis FISH for Turner
Alpha1AT Defic Profile FISH for Williams
Angelman/Prader Willi (15q11-q13) by FISH FISH for Wolf-hirschhorn
Angelman/Prader Willi mPCR FISH for XX and XY
CF Carrier Screening by Sequenom FISHAneuTCPanel
CF DNA FISHAneuVysion
CF Gene Sequencing to MAYO FISHDiGeorge
Chromosomal Microarray (CGH) FISHDownSyn
Chromosome Analysis Constitutional FISHMillerDieke
Chromosome Analysis POC FISHPraderWilli
Chromosome Analysis Prenatal FISHSmithMageni
Factor V Leiden DNA Analysis FISHSubtelomeres
FISH for aneuVysion FISHWilliams
FISH for Common trisomies in POC FISHWolf
FISH for DiGeorge FISHXXYYSRY
FISH for Down syndrome Hemochromatosis DNA
FISH for Major trisomies Huntington’s Disease Molecular Analysis
FISH for Miller-dieker MTHFR C677T
FISH for Prader-willi Prothrombin G20210A
FISH for Smith-Magenis Send Out CMA
FISH for Subtelomeres