POCT Audits

Holly,

can you define what you mean by comparing structures?

Did the original post get deleted so the question no longer is viable?

Sorry I'm confused since I see two posts but one says [deleted]

Greg,

I am trying to compare with other facilities that utilize POC audit tools, to see if I can add to mine or change some items.

Peggy,

Sorry for any confusion, I placed the post twice and deleted one.

We are currently auditing:

• Specimen rejections (QNS, clotted, mislabeled/unlabeled, incorrect sample type)


• Timer and thermometer certifications (sometimes clinic bring in non-certified (non-calibrated) timers and we remove them from use or calibrate them


• QC exception tracking (QC not properly documented, QC accepted that was not within established tolerance limits


• Manual test logs have test kit lot #'s and expiration dates completed


• Test kits/reagents have "opened for use" dates and modified expiration dates (when expiration date is shortened once opened)


• Test kits/reagents are properly marked that they were QC'd


• Ambient temp and refrigerator temps are properly recorded and within specified ranges (we do not have remote monitoring systems for POC locations


• Expiration dates of all supplies (test kits, collection supplies) have not passed expiration.

Along with what Greg has listed we (I) include the following:

-Monthly review of POCT control/results manually entered into the EMR by performer (I receive from our IS department listings for pH, Upreg and Occult blood)

-Daily random verification of caregiver orders to test(s) performed

-Annual interface study

Along with Greg, 

we also monitor:

-Critical documentation & action

-operator competency

-incorrect/nonconfirmed ID's

-eoc rounds on teh units

-corrected reports

-tissue tracking audits

Shana,

What is your benchmark for Critical documentation?  We currently are set for 100%    We run about 97%.  My CNO asked me to find out what other places benchmark are.

We also monitor confirmed to laboratory <10 >600 for BGM. That benchmark is also at 100% of the time, and we are running 75% of the time.

QC comments for BGM should be 100%; we run 98%